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NCLEX Psychiatric Nursing questions & answers part 1
1. A nurse is assessing a client who is experiencing
occasional feelings of sadness because of the recent death of a beloved pet.
The client’s appetite, sleep patterns, and daily routine have not changed. How
should the nurse interpret the client’s behaviors?
1. The client’s behaviors demonstrate mental illness
in the form of depression.
2. The client’s behaviors are extensive, which
indicates the presence of mental illness.
3. The client’s behaviors are not congruent with
cultural norms.
4. The client’s behaviors demonstrate no functional
impairment, indicating no mental illness.
ANS: 4
Rationale: The nurse should assess that the client’s
daily functioning is not impaired. The client who experiences feelings of
sadness after the loss of a pet is responding within normal expectations.
Without significant impairment, the client’s distress does not indicate a
mental illness.
2. At what point should the nurse determine that a
client is at risk for developing a mental illness?
1. When thoughts, feelings, and behaviors are not
reflective of the DSM-5 criteria.
2. When maladaptive responses to stress are coupled
with interference in daily functioning.
3. When a client communicates significant distress.
4. When a client uses defense mechanisms as ego
protection.
ANS: 2
Rationale: The nurse should determine that the client
is at risk for mental illness when responses to stress are maladaptive and
interfere with daily functioning. The DSM-5 indicates that in order to be
diagnosed with a mental illness, daily functioning must be significantly
impaired. The client’s ability to communicate distress would be considered a
positive attribute.
3. A nurse is assessing a set of 15-year-old identical
twins who respond very differently to stress. One twin becomes anxious and
irritable, and the other withdraws and cries. How should the nurse explain
these different stress responses to the parents?
1. Reactions to stress are relative rather than
absolute; individual responses to stress vary.
2. It is abnormal for identical twins to react
differently to similar stressors.
3. Identical twins should share the same temperament
and respond similarly to stress.
4. Environmental influences to stress weigh more
heavily than genetic influences.
ANS: 1
Rationale: The nurse should explain to the parents
that, although the twins have identical DNA, there are several other factors
that affect reactions to stress. Mental health is a state of being that is
relative to the individual client. Environmental influences and temperament can
affect stress reactions.
4. Which client should the nurse anticipate to be most
receptive to psychiatric treatment?
1. A Jewish, female social worker.
2. A Baptist, homeless male.
3. A Catholic, black male.
4. A Protestant, Swedish business executive.
ANS: 1
Rationale: The nurse should anticipate that the client
of Jewish culture would place a high importance on preventative health care and
would consider mental health as equally important as physical health. Women are
also more likely to seek treatment for mental health problems than men.
5. A psychiatric nurse intern states, “This client’s
use of defense mechanisms should be eliminated.” Which is a correct evaluation
of this nurse’s statement?
1. Defense mechanisms can be appropriate responses to
stress and need not be eliminated.
2. Defense mechanisms are a maladaptive attempt of the
ego to manage anxiety and should always be eliminated.
3. Defense mechanisms, used by individuals with weak
ego integrity, should be discouraged and not eliminated.
4. Defense mechanisms cause disintegration of the ego
and should be fostered and encouraged.
ANS: 1
Rationale: The nurse should determine that defense
mechanisms can be appropriate during times of stress. The client with no
defense mechanisms may have a lower tolerance for stress, thus leading to
anxiety disorders. Defense mechanisms should be confronted when they impede the
client from developing healthy coping skills.`
6. During an intake assessment, a nurse asks both
physiological and psychosocial questions. The client angrily responds, “I’m
here for my heart, not my head problems.” Which is the nurse’s best response?
1. “It’s just a routine part of our assessment. All
clients are asked these same questions.”
2. “Why are you concerned about these types of
questions?”
3. “Psychological factors, like excessive stress, have
been found to affect medical conditions.”
4. “We can skip these questions, if you like. It isn’t
imperative that we complete this section.”
ANS: 3
Rationale: The nurse should attempt to educate the
client on the negative effects of excessive stress on medical conditions. It is
not appropriate to skip physiological and psychosocial questions, as this would
lead to an inaccurate assessment.
7. An employee uses the defense mechanism of
displacement when the boss openly disagrees with suggestions. What behavior
would be expected from this employee?
1. The employee assertively confronts the boss.
2. The employee leaves the staff meeting to work out
in the gym.
3. The employee criticizes a coworker.
4. The employee takes the boss out to lunch.
ANS: 3
Rationale: The nurse should expect that the client
using the defense mechanism displacement would criticize a coworker after being
confronted by the boss. Displacement refers to transferring feelings from one
target to a neutral or less-threatening target.
8. A fourth-grade boy teases and makes jokes about a
cute girl in his class. This behavior should be identified by a nurse as
indicative of which defense mechanism?
1. Displacement
2. Projection
3. Reaction formation
4. Sublimation
ANS: 3
Rationale: The nurse should identify that the boy is
using reaction formation as a defense mechanism. Reaction formation is the
attempt to prevent undesirable thoughts from being expressed by expressing
opposite thoughts or behaviors. Displacement refers to transferring feelings
from one target to another. Rationalization refers to making excuses to justify
behavior. Projection refers to the attribution of unacceptable feelings or
behaviors to another person. Sublimation refers to channeling unacceptable
drives or impulses into more constructive, acceptable activities.
9. Which nursing statement about the concept of
neurosis is most accurate?
1. An individual experiencing neurosis is unaware that
he or she is experiencing distress.
2. An individual experiencing neurosis feels helpless
to change his or her situation.
3. An individual experiencing neurosis is aware of
psychological causes of his or her behavior.
4. An individual experiencing neurosis has a loss of
contact with reality.
ANS: 2
Rationale: The nurse should define the concept of
neurosis with the following characteristics: The client feels helpless to
change his or her situation, the client is aware that he or she is experiencing
distress, the client is aware the behaviors are maladaptive, the client is
unaware of the psychological causes of the distress, and the client experiences
no loss of contact with reality.
10. Which nursing statement regarding the concept of
psychosis is most accurate?
1. Individuals experiencing psychoses are aware that
their behaviors are maladaptive.
2. Individuals experiencing psychoses experience
little distress.
3. Individuals experiencing psychoses are aware of
experiencing psychological problems.
4. Individuals experiencing psychoses are based in
reality.
ANS: 2
Rationale: The nurse should understand that the client
with psychosis experiences little distress owing to his or her lack of
awareness of reality. The client with psychosis is unaware that his or her
behavior is maladaptive or that he or she has a psychological problem.
11. When under stress, a client routinely uses alcohol
to excess. Finding her drunk, her husband yells at the client about her chronic
alcohol abuse. Which action alerts the nurse to the client’s use of the defense
mechanism of denial?
1. The client hides liquor bottles in a closet.
2. The client yells at her son for slouching in his
chair.
3. The client burns dinner on purpose.
4. The client says to the spouse, “I don’t drink too
much!”
ANS: 4
Rationale: The client’s statement “I don’t drink too
much!” alerts the nurse to the use of the defense mechanism of denial. The
client is refusing to acknowledge the existence of a real situation and the
feelings associated with it.
12. Devastated by a divorce from an abusive husband, a
wife completes grief counseling. Which statement by the wife should indicate to
a nurse that the client is in the acceptance stage of grief?
1. “If only we could have tried again, things might
have worked out.”
2. “I am so mad that the children and I had to put up
with him as long as we did.”
3. “Yes, it was a difficult relationship, but I think
I have learned from the experience.”
4. “I still don’t have any appetite and continue to
lose weight.”
ANS: 3
Rationale: The nurse should evaluate that the client
is in the acceptance stage of grief because during this stage of the grief
process, the client would be able to focus on the reality of the loss and its
meaning in relation to life.
13. A nurse is performing a mental health assessment
on an adult client. According to Maslow’s hierarchy of needs, which client
action would demonstrate the highest achievement in terms of mental health?
1. Maintaining a long-term, faithful, intimate relationship.
2. Achieving a sense of self-confidence.
3. Possessing a feeling of self-fulfillment and
realizing full potential.
4. Developing a sense of purpose and the ability to
direct activities.
ANS: 3
Rationale: The nurse should identify that the client who
possesses a feeling of self-fulfillment and realizes his or her full potential
has achieved self-actualization, the highest level on Maslow’s hierarchy of
needs.
14. According to Maslow’s hierarchy of needs, which
situation on an in-patient psychiatric unit would require priority intervention
by a nurse?
1. A client rudely complaining about limited visiting
hours.
2. A client exhibiting aggressive behavior toward
another client.
3. A client stating that no one cares.
4. A client verbalizing feelings of failure.
ANS: 2
Rationale: The nurse should immediately intervene when
a client exhibits aggressive behavior toward another client. Safety and
security are considered lower-level needs according to Maslow’s hierarchy of
needs and must be fulfilled before other higher-level needs can be met. Clients
who complain, have feelings of failure, or state that no one cares are
struggling with higher-level needs such as the need for love and belonging or
the need for self-esteem.
15. How would a nurse best complete the new DSM-5
definition of a mental disorder? “A health condition characterized by
significant dysfunction in an individual’s cognitions, or behaviors that
reflects a disturbance in the
1. psychosocial, biological, or developmental process
underlying mental functioning.”
2. psychological, cognitive, or developmental process
underlying mental functioning.”
3. psychological, biological, or developmental process
underlying mental functioning.”
4. psychological, biological, or psychosocial process
underlying mental functioning.”
ANS: 3
Rationale: “A health condition characterized by
significant dysfunction in an individual’s cognitions, or behaviors that
reflects a disturbance in the psychological, biological, or developmental
process underlying mental functioning”, is the new DSM 5 definition of a mental
disorder.
16. A nurse is assessing a client who appears to be
experiencing some anxiety during questioning. Which symptoms might the client
demonstrate that would indicate anxiety? (Select all that apply.)
1. Fidgeting
2. Laughing inappropriately
3. Palpitations
4. Nail biting
5. Limited attention span
ANS: 1, 2, 4
Rationale: The nurse should assess that fidgeting,
laughing inappropriately, and nail biting are indicative of heightened stress
levels. The client would not be diagnosed with mental illness unless there is
significant impairment in other areas of daily functioning. Other indicators of
more serious anxiety are restlessness, difficulty concentrating, muscle
tension, and sleep disturbance.
17. A jilted college student is admitted to a hospital
following a suicide attempt and states, “No one will ever love a loser like
me.” According to Erikson’s theory of personality development, a nurse should
recognize that this patient has a deficit in which developmental stage?
1. Trust versus mistrust
2. Initiative versus guilt
3. Intimacy versus isolation
4. Ego integrity versus despair
ANS: 3
Rationale: The nurse should recognize that the client
who states, “No one will ever love a loser like me” has not adequately
completed the intimacy versus isolation stage of development. The intimacy
versus isolation stage is presumed to occur in young adulthood between the ages
of 20 and 30 years. The major developmental task in this stage is to establish
intense, lasting relationships or commitment to another person, cause,
institution, or creative effort.
18. A nurse observes a 3-year-old client willingly
sharing candy with a sibling. According to Peplau, which psychological stage of
development should the nurse determine that this child has completed?
1. Learning to count on others
2. Learning to delay satisfaction
3. Identifying oneself
4. Developing skills in participation
ANS: 2
Rationale: The nurse should determine that this client
has completed the learning to delay satisfaction stage of development,
according to Peplau’s interpersonal theory. This stage typically occurs in
toddlerhood when one learns the satisfaction of pleasing others.
19. A 9-month-old child screams every time his mother
leaves and will not tolerate anyone else changing his diaper. The nurse should
determine that, according to Mahler’s developmental theory, this child’s
development was arrested at which phase?
1. The autistic phase
2. The symbiotic phase
3. The separation-individuation phase
4. The rapprochement phase
ANS: 2
Rationale: The nurse should understand that this
client’s development was halted in the symbiotic phase of Mahler’s
developmental theory, which usually occurs between 1 and 5 months of age. The
child has not entered into the separation-individuation phase of development,
in which a child establishes the understanding of being separate from the
mother.
20. According to Peplau, a nurse who provides an
abandoned child with parental guidance and praise following small accomplishments
is serving which therapeutic role?
1. Technical expert
2. Resource person
3. Surrogate
4. Leader
ANS: 3
Rationale: The nurse who provides an abandoned child
with parental guidance and praise is serving the role of the surrogate,
according to Peplau’s interpersonal theory. A surrogate serves as a substitute
for another person—in this case, the child’s parent.
21. When assessing clients, a psychiatric nurse should
understand that psychoanalytic theory is based on which underlying concept?
1. A possible genetic basis for the client’s problems
2. The structure and dynamics of the personality
3. Behavioral responses to stressors
4. Maladaptive cognitions
ANS: 2
Rationale: The nurse should understand that
psychoanalytic theory is based on the underlying concepts of the structure and
dynamics of personality. Psychoanalytic theory was developed by Sigmund Freud
and explains the structure of personality in three different components: the
id, the ego, and the superego.
22. Which underlying concept should a nurse associate
with interpersonal theory when assessing a client?
1. The effects of social processes on personality
development
2. The effects of unconscious processes and
personality structures
3. The effects on thoughts and perceptual processes
4. The effects of chemical and genetic influences
ANS: 1
Rationale: The nurse should associate interpersonal
theory with the underlying concept of effects of social process on personality
development. Sullivan developed stages of personality development based on his
theory of interpersonal relationships and their effect on personality and
individual behavior.
23. A physically healthy, 35-year-old, single client
lives with parents, who provide total financial support. According to Erikson’s
theory, which developmental task should a nurse assist the client to
accomplish?
1. Establishing the ability to control emotional
reactions
2. Establishing a strong sense of ethics and character
structure
3. Establishing and maintaining self-esteem
4. Establishing a career, personal relationships, and
societal connections
ANS: 4
Rationale: The nurse should assist the client in
establishing a career, personal relationships, and societal connections.
According to Erikson, nonachievement of the generativity versus stagnation
stage results in self-absorption, including withdrawal from others and having
no capacity for giving of the self to others.
24. A 1-month-old infant is left alone for extended
periods, has little physical stimulation, and is malnourished. Based on this
infant’s situation, in which phase of development, according to Mahler’s
theory, should a nurse expect to see a potential deficit?
1. The symbiotic phase
2. The autistic phase
3. The consolidation phase
4. The rapprochement phase
ANS: 2
Rationale: The nurse should expect that a 1-month-old
infant who is left alone, has little physical stimulation, and is malnourished
would not meet the autistic phase of development. The autistic phase of
development usually occurs from birth to 1 month, at which time the infant’s
focus is on basic needs and comfort.
25. A 6-year-old boy uses his father’s flashlight to
explore his 3-year-old sister’s genitalia. According to Freud, in which stage
of psychosocial development should a nurse identify this behavior as normal?
1. Oral
2. Anal
3. Phallic
4. Latency
ANS: 3
Rationale: The nurse should identify this behavior as
normal, because the 6-year-old client who focuses on genital organs is in the
phallic stage of Freud’s psychosexual stages of development. Children in the
phallic stage of development focus on genital organs and develop a sense of
sexual identity. Identification with the same-sex parent also occurs at this
stage.
26. A married, 26-year-old client works as a
schoolteacher. She and her husband have just had their first child. A nurse
should recognize that this client is successfully accomplishing which stage of
Erikson’s developmental theory?
1. Industry versus inferiority
2. Identity versus role confusion
3. Intimacy versus isolation
4. Generativity versus stagnation
ANS: 3
Rationale: The nurse should recognize that a
26-year-old client who is married and has a child has successfully accomplished
the intimacy versus isolation stage of Erikson’s developmental theory. The
intimacy versus isolation stage of young adulthood involves forming lasting
relationships. Achievement of this task results in the capacity for mutual love
and respect.
27. A 10-year-old child wins the science fair
competition and is chosen as a cheerleader for the basketball team. A nurse should
recognize that this child is in the process of successfully accomplishing which
stage of Erikson’s developmental theory?
1. Industry versus inferiority
2. Identity versus role confusion
3. Intimacy versus isolation
4. Generativity versus stagnation
ANS: 1
Rationale: The nurse should recognize that a
10-year-old child who is successful in school both academically and socially
has effectively accomplished the industry versus inferiority developmental
stage of Erikson’s psychosocial theory. The industry versus inferiority stage
of development usually occurs between 6 and 12 years of age, at which time
individuals achieve a sense of self-confidence by learning, competing,
performing successfully, and receiving recognition from others.
28. A client has flashbacks of sexual abuse by her
uncle. She had not had these memories until recently, when she became sexually
active with her boyfriend. A nurse should identify this experience as which
part of Sullivan’s concept of the self-system?
1. The good me
2. The bad me
3. The not me
4. The bad you
ANS: 3
Rationale: The nurse should identify a client
remembering sexual abuse when becoming sexually active with her boyfriend as
experiencing the not me part of the personality. According to Sullivan, the not
me part of the personality develops in response to situations that produced
intense anxiety in childhood.
29. According to Freud, which statement should a nurse
associate with predominance of the superego?
1. “No one is looking, so I will take three cigarettes
from Mom’s pack.”
2. “I don’t ever cheat on tests; it is wrong.”
3. “If I skip school, I will get into trouble and fail
my test.”
4. “Dad won’t miss this little bit of vodka.”
ANS: 2
Rationale: The nurse should associate the statement “I
don’t ever cheat on tests; it is wrong” as indicative of the predominance of
the superego. Freud described the superego as the part of the personality that
internalizes the values and morals set forth by primary caregivers. The
superego can be referred to as the “perfection principle.”
30. A female complains that her husband only satisfies
his sexual needs and never her needs. According to Freud, which personality
structure should a nurse identify as predominantly driving the husband’s
actions?
1. The id
2. The superid
3. The ego
4. The superego
ANS: 1
Rationale: The nurse should identify that the
husband’s actions are driven by the predominance of the id. According to Freud,
the id is the part of the personality that is identified as the pleasure
principle. The id is the locus of instinctual drives.
31. A father of a 5-year-old demeans and curses his
child for disobedience. In turn, when upset, the child uses swear words at
kindergarten. A school nurse recognizes this behavior as unsuccessful
completion of which stage of development, according to Peplau?
1. Learning to count on others
2. Learning to delay satisfaction
3. Identifying oneself
4. Developing skills in participation
ANS: 3
Rationale: The nurse should identify that the child
using swear words in kindergarten has not successfully completed the
identifying oneself stage, according to Peplau’s interpersonal theory. During
this stage of early childhood, a child learns to structure self-concept by
observing how others interact with him or her.
32. A nurse is caring for a hospitalized client who is
quarrelsome, opinionated, and has little regard for others. According to
Sullivan’s interpersonal theory, the nurse should associate the client’s
behaviors with a previous deficit in which stage of development?
1. Infancy
2. Childhood
3. Early adolescence
4. Late adolescence
ANS: 2
Rationale: The nurse should associate the client’s
behavior with a deficit in the childhood stage of Sullivan’s interpersonal
theory. The childhood stage in Sullivan’s interpersonal theory typically occurs
from 18 months to 6 years of age, during which the child learns to experience a
delay in personal gratification without undue anxiety
33. Which of the following concepts should a nurse
identify as being included in Black and Andreasen’s definition of personality?
(Select all that apply.)
1. Personality is the characteristic way in which a
person thinks, feels, and behaves.
2. Personality is the ingrained pattern of behavior
that each person evolves, both consciously and unconsciously.
3. Personality is developed in sporadic stages that
vary from person to person and experience to experience.
4. Personality has to do with a person’s style of life
or way of being.
5. Personality is inborn and cannot be influenced by
developmental progression.
ANS: 1, 2, 4
Rationale: Black and Andreasen (2011) define
personality as “the characteristic way in which a person thinks, feels, and
behaves; the ingrained pattern of behavior that each person evolves, both
consciously and unconsciously, as his or her style of life or way of being.”
34. A depressed client states, “I have a chemical
imbalance in my brain. I have no control over my behavior. Medications are my
only hope to feel normal again.” Which nursing response is appropriate?
1. “Medications only address biological factors.
Environmental and interpersonal factors must also be considered.”
2. “Because biological factors are the sole cause of
depression, medications will improve your mood.”
3. “Environmental factors have been shown to exert the
most influence in the development of depression.”
4. “Researchers have been unable to demonstrate a link
between nature (biology and genetics) and nurture (environment).”
ANS: 1
Rationale: The nurse should advise the client that
medications address biological factors, but there are other factors that affect
mood. The nurse should educate the client on environmental and interpersonal
factors that can lead to depression.
35. A client diagnosed with major depressive disorder
asks, “What part of my brain controls my emotions?” Which nursing response is
appropriate?
1. “The occipital lobe governs perceptions, judging
them as positive or negative.”
2. “The parietal lobe has been linked to depression.”
3. “The medulla regulates key biological and
psychological activities.”
4. “The limbic system is largely responsible for one’s
emotional state.”
ANS: 4
Rationale: The nurse should explain to the client that
the limbic system is largely responsible for one’s emotional state. This system
if often called the “emotional brain” and is associated with feelings,
sexuality, and social behavior. The occipital lobes are the area of visual
reception and interpretation. Somatosensory input (touch, taste, temperature,
etc.) occurs in the parietal lobes. The medulla contains vital centers that
regulate heart rate and reflexes.
36. Which part of the nervous system should a nurse
identify as playing a major role during stressful situations?
1. Peripheral nervous system 2. Somatic nervous system
3. Sympathetic nervous system
4. Parasympathetic nervous system
ANS: 3
Rationale: The nurse should identify that the
sympathetic nervous system plays a major role during stressful situations. The
sympathetic nervous system prepares the body for the fight-or-flight response.
The parasympathetic nervous system is dominant when an individual is in a
nonstressful state.
37. Which client statement reflects an understanding
of circadian rhythms in psychopathology?
1. “When I dream about my mother’s horrible train
accident, I become hysterical.” 2. “I get really irritable during my menstrual
cycle.”
3. “I’m a morning person. I get my best work done
before noon.”
4. “Every February, I tend to experience periods of
sadness.”
ANS: 3
Rationale: By stating, “I am a morning person,” the
client demonstrates an understanding that circadian rhythms may influence a
variety of regulatory functions, including the sleep-wake cycle, regulation of
body temperature, and patterns of activity. Most humans follow a 24-hour cycle
that is largely affected by lightness and darkness.
38. Which types of adoption studies should a nurse
recognize as providing useful information for the psychiatric community?
1. Studies in which children with mentally ill
biological parents are raised by adoptive parents who were mentally healthy.
2. Studies in which children with mentally healthy
biological parents are raised by adoptive parents who were mentally ill.
3. Studies in which monozygotic twins from mentally
ill parents were raised separately by different adoptive parents.
4. Studies in which monozygotic twins were raised
together by mentally ill biological parents.
5. All of the above.
ANS: 5
Rationale: The nurse should determine that all of the
studies could possibly benefit the psychiatric community. The studies may reveal
research findings relating genetic links to mental illness. Adoption studies
allow comparisons to be made of the influences of the environment versus
genetics.
39. Six months after her husband and children were
killed in a car accident, a client is diagnosed with ulcerative colitis. The
nurse should recognize that this situation validates which study perspective?
1. Neuroendocrinology
2. Psychoimmunology
3. Diagnostic technology
4. Neurophysiology
ANS: 2
Rationale: Psychoimmunology is the branch of medicine
that studies the effects of social and psychological factors on the functioning
of the immune system. Studies of the biological response to stress hypothesize
that individuals become more susceptible to physical illness following exposure
to stressful stimuli.
40. A withdrawn client, diagnosed with schizophrenia,
expresses little emotion and refuses to attend group therapy. What altered
component of the nervous system should a nurse recognize as being responsible
for this behavior?
1. Dendrites
2. Axons
3. Neurotransmitters
4. Synapses
ANS: 3
Rationale: The nurse should recognize that
neurotransmitters play an essential function in the role of human emotion and
behavior. Neurotransmitters are targeted and affected by many psychotropic
medications.
41. An instructor is teaching nursing students about
neurotransmitters. Which best explains the process of how neurotransmitters
released into the synaptic cleft may return to the presynaptic neuron?
1. Regeneration
2. Reuptake
3. Recycling
4. Retransmission
ANS: 2
Rationale: The nursing instructor should explain that
the process by which neurotransmitters are released into the synaptic cleft and
returned to the presynaptic neuron is termed reuptake. Reuptake is the process
by which neurotransmitters are stored for reuse.
42. A nurse concludes that a restless, agitated client
is manifesting a fight- or-flight response. The nurse should associate this
response with which neurotransmitter?
1. Acetylcholine
2. Dopamine
3. Serotonin
4. Norepinephrine
ANS: 4
Rationale: The nurse should associate the
neurotransmitter norepinephrine with the fight-or-flight response.
Norepinephrine produces activity in the sympathetic postsynaptic nerve terminal
and is associated with the regulation of mood, cognition, perception,
locomotion, and sleep and arousal.
43. A client is admitted to a psychiatric unit with
the diagnosis of catatonic schizophrenia. Which of the client’s
neurotransmitters should a nurse expect to be elevated?
1. Serotonin
2. Dopamine
3. Gamma-aminobutyric acid (GABA)
4. Histamine
ANS: 2
Rationale: The nurse should expect that elevated
dopamine levels might be an attributing factor to the client’s current level of
functioning. Dopamine functions include regulation of movements and
coordination, emotions, and voluntary decision-making ability.
44. A client’s wife of 34 years dies unexpectedly. The
client cries often and becomes socially isolated. The client’s therapist
encourages open discussion of feelings, proper nutrition, and exercise. What is
the best rationale for the therapist’s recommendations?
1. The therapist is using an interpersonal approach.
2. The client has an alteration in neurotransmitters.
3. It is routine practice to remind clients about
nutrition, exercise, and rest.
4. The client is susceptible to illness because of
effects of stress on the immune system.
ANS: 4
Rationale: The therapist’s recommendations should be
based on the knowledge that the client has been exposed to stressful stimuli
and is at an increased risk to develop illness because of the effects of stress
on the immune system. The study of this branch of medicine is called
psychoimmunology.
45. Which mental illness should a nurse identify as
being associated with a decrease in prolactin hormone level?
1. Major depressive episode
2. Schizophrenia
3. Anorexia nervosa
4. Alzheimer’s disease
ANS: 2
Rationale: Although the exact mechanism is unknown,
there may be some correlation between decreased levels of the hormone prolactin
and schizophrenia.
46. Which cerebral structure should a nursing
instructor describe to students as the “emotional brain”?
1. The cerebellum
2. The limbic system
3. The cortex
4. The left temporal lobe
ANS: 2
Rationale: The limbic system is often referred to as
the “emotional brain.” The limbic system is largely responsible for one’s
emotional state and is associated with feelings, sexuality, and social
behavior.
47. A nurse understands that the abnormal secretion of
growth hormone may play a role in which illness?
1. Acute mania
2. Schizophrenia
3. Anorexia nervosa
4. Alzheimer’s disease
ANS: 3
Rationale: The nurse should understand that research
has found a correlation between abnormal levels of growth hormone and anorexia
nervosa. The growth hormone is responsible for growth in children, as well as continued
protein synthesis throughout life.
48. A client is admitted to an emergency department
experiencing memory deficits and decreased motor function. What alteration in
brain chemistry should a nurse correlate with the production of these symptoms?
1. Abnormal levels of serotonin
2. Decreased levels of dopamine
3. Increased levels of norepinephrine
4. Decreased levels of acetylcholine
ANS: 4
Rationale: The nurse should correlate memory deficits
and decreased motor function with decreased levels of acetylcholine.
Acetylcholine is a major effector chemical of the autonomic nervous system.
Functions of acetylcholine include sleep regulation, pain perception, the
modulation and coordination of movement, and memory.
49. A nurse should recognize that a decrease in
norepinephrine levels would play a significant role in which mental illness?
1. Bipolar disorder: mania
2. Schizophrenia spectrum disorder
3. Generalized anxiety disorder
4. Major depressive episode
ANS: 4
Rationale: The nurse should recognize that a decrease
in norepinephrine level would play a significant role in the development of
major depressive disorder. The functions of norepinephrine include the
regulation of mood, cognition, perception, locomotion, cardiovascular
functioning, and sleep and arousal.
50. A nurse should expect that an increase in dopamine
activity might play a significant role in the development of which mental
illness?
1. Schizophrenia spectrum disorder
2. Major depressive disorder
3. Body dysmorphic disorder
4. Parkinson’s disease
ANS: 1
Rationale: The nurse should expect that an increase in
dopamine activity might play a significant role in the development of
schizophrenia spectrum disorder. Functions of dopamine include regulation of
emotions, coordination, and voluntary decision-making ability. Increased
dopamine activity is also associated with mania.
51. Which of the following information should a nurse
include when explaining causes of anorexia nervosa to a client? (Select all
that apply.)
1. There is a possible correlation between abnormal
secretion of growth hormone and anorexia nervosa.
2. There is a possible correlation between
antidiuretic hormone levels and anorexia nervosa.
3. There is a possible correlation between low levels
of gonadotropin and anorexia nervosa.
4. There is a possible correlation between increased
levels of prolactin and anorexia nervosa.
5. There is a possible correlation between altered
levels of oxytocin and anorexia nervosa.
ANS: 1, 3
Rationale: The nurse should explain to the client that
there is a possible correlation between anorexia nervosa and decreased levels
of growth hormones and gonadotropin. Anorexia nervosa has also been correlated
with increased cortisol levels.
52. Which of the following symptoms should a nurse
associate with the development of increased levels of thyroid-stimulating
hormone (TSH) in a newly admitted client? (Select all that apply.)
1. Depression
2. Fatigue
3. Increased libido
4. Mania
5. Hyperexcitability
ANS: 1, 2
Rationale: The nurse should associate depression and
fatigue with increased levels of TSH. TSH is only increased when thyroid levels
are low, as in the diagnosis of hypothyroidism. In addition to depression and
fatigue, other symptoms, such as decreased libido, memory impairment, and
suicidal ideation are associated with chronic hypothyroidism.
53. In response to a student’s question regarding
choosing a psychiatric specialty, a charge nurse states, “Mentally ill clients
need special care. If I were in that position, I’d want a caring nurse also.”
From which ethical framework is the charge nurse operating?
1. Kantianism
2. Christian ethics
3. Ethical egoism
4. Utilitarianism
ANS: 2
Rationale: The charge nurse is operating from a
Christian ethics framework. The imperative demand of Christian ethics is that
all decisions about right and wrong should be centered in love for God and in
treating others with the same respect and dignity with which we would expect to
be treated. Kantianism states that decisions should be made based on moral law
and that actions are bound by a sense of moral duty. Utilitarianism holds that
decisions should be made focusing on the end result being happiness. Ethical
egoism promotes the idea that what is right is good for the individual.
54. During a hiring interview, which response by a
nursing applicant should indicate that the applicant operates from an ethical
egoism framework?
1. “I would want to be treated in a caring manner if I
were mentally ill.”
2. “This job will pay the bills, and the workload is
light enough for me.”
3. “I will be happy caring for the mentally ill.
Working in med/surg kills my back.”
4. “It is my duty in life to be a psychiatric nurse.
It is the right thing to do.”
ANS: 2
Rationale: The applicant’s comment reflects the
ethical egoism framework. This framework promotes the idea that decisions are
made based on what is good for the individual and may not take the needs of
others into account.
55. Without authorization, a nurse administers an
extra dose of narcotic tranquilizer to an agitated client. The nurse’s coworker
observes this action but does nothing for fear of retaliation. What is the
ethical interpretation of the coworker’s lack of involvement?
1. Taking no action is still considered an unethical
action by the coworker.
2. Taking no action releases the coworker from ethical
responsibility.
3. Taking no action is advised when potential adverse
consequences are foreseen.
4. Taking no action is acceptable, because the
coworker is only a bystander.
ANS: 1
Rationale: The coworker’s lack of involvement can be
interpreted as an unethical action. The coworker is experiencing an ethical
dilemma in which a decision needs to be made between two unfavorable
alternatives. The coworker has a responsibility to report any observed
unethical actions.
56. Group therapy is strongly encouraged, but not
mandatory, in an inpatient psychiatric unit. The unit manager’s policy is that
clients can make a choice about whether or not to attend group therapy. Which
ethical principle does the unit manager’s policy preserve?
1. Justice
2. Autonomy
3. Veracity
4. Beneficence
ANS: 2
Rationale: The unit manager’s policy regarding
voluntary client participation in group therapy preserves the ethical principle
of autonomy. The principle of autonomy presumes that individuals are capable of
making independent decisions for themselves and that health-care workers must
respect these decisions.
57. Which is an example of an intentional tort?
1. A nurse fails to assess a client’s obvious symptoms
of neuroleptic malignant syndrome.
2. A nurse physically places an irritating client in
four-point restraints.
3. A nurse makes a medication error and does not
report the incident.
4. A nurse gives patient information to an
unauthorized person.
ANS: 2
Rationale: A tort, which can be intentional or
unintentional, is a violation of civil law in which an individual has been
wronged. A nurse who intentionally physically places an irritating client in
restraints has touched the client without consent and has committed an
intentional tort.
58. An involuntarily committed client is verbally
abusive to the staff, repeatedly threatening to sue. The client records the
full names and phone numbers of the staff. Which nursing action is most
appropriate to decrease the possibility of a lawsuit?
1. Verbally redirect the client, and then refuse
one-on-one interaction.
2. Involve the hospital’s security division as soon as
possible.
3. Notify the client that documenting personal staff
information is against hospital policy.
4. Continue professional attempts to establish a
positive working relationship with the client.
ANS: 4
Rationale: The most appropriate nursing action is to
continue professional attempts to establish a positive working relationship
with the client. The involuntarily committed client should be respected and has
the right to assert grievances if rights are infringed.
59. Which statement should a nurse identify as correct
regarding a client’s right to refuse treatment?
1. Clients can refuse pharmacological but not
psychological treatment.
2. Clients can refuse any treatment at any time.
3. Clients can refuse only electroconvulsive therapy
(ECT).
4. Professionals can override treatment refusal by an
actively suicidal or homicidal client.
ANS: 4
Rationale: The nurse should understand that
health-care professionals could override treatment refusal when a client is
actively suicidal or homicidal. A suicidal or homicidal client who refuses
treatment may be in danger or a danger to others. This situation should be
treated as an emergency, and treatment may be performed without informed
consent.
60. Which potential client should a nurse identify as
a candidate for involuntarily commitment?
1. The client living under a bridge in a cardboard box
2. The client threatening to commit suicide
3. The client who never bathes and wears a wool hat in
the summer
4. The client who eats waste out of a garbage can
ANS: 2
Rationale: The nurse should identify the client
threatening to commit suicide as eligible for involuntary commitment. The
suicidal client who refuses treatments is in danger and needs emergency
treatment.
61. A client diagnosed with schizophrenia refuses to
take medication, citing the right of autonomy. Under which circumstance would a
nurse have the right to medicate the client against the client’s wishes?
1. A client makes inappropriate sexual innuendos to a
staff member.
2. A client constantly demands attention from the
nurse by begging, “Help me get better.”
3. A client physically attacks another client after
being confronted in group therapy.
4. A client refuses to bathe or perform hygienic
activities.
ANS: 3
Rationale: The nurse would have the right to medicate
a client against his or her wishes if the client physically attacks another
client. This client poses a significant risk to safety and is incapable of
making informed choices. The client’s refusal to accept treatment can be
challenged, because the client is endangering the safety of others.
62. A psychiatric nurse working on an inpatient unit
receives a call asking if an individual has been a client in the facility.
Which nursing response reflects appropriate legal and ethical obligations?
1. The nurse refuses to give any information to the
caller, citing rules of confidentiality.
2. The nurse hangs up on the caller.
3. The nurse confirms that the person has been at the
facility but adds no additional information.
4. The nurse suggests that the caller speak to the
client’s therapist.
ANS: 1
Rationale: The most appropriate action by the nurse is
to refuse to give any information to the caller. Admission to the facility
would be considered protected health information (PHI) and should not be
disclosed by the nurse without prior client consent.
63. A client requests information on several
medications in order to make an informed choice about management of depression.
A nurse should provide this information to facilitate which ethical principle?
1. Autonomy
2. Beneficence
3. Nonmaleficence
4. Justice
ANS: 1
Rationale: The nurse should provide the information to
support the client’s autonomy. A client who is capable of making independent
choices should be permitted to do so. In instances when clients are incapable
of making informed decisions, a legal guardian or representative would be asked
to give consent.
64. An inpatient psychiatric physician refuses to
treat clients without insurance and prematurely discharges those whose
insurance benefits have expired. Which ethical principle should a nurse
determine has been violated based on these actions?
1. Autonomy
2. Beneficence
3. Nonmaleficence
4. Justice
ANS: 4
Rationale: The nurse should determine that the ethical
principle of justice has been violated by the physician’s actions. The
principle of justice requires that individuals should be treated equally,
regardless of race, sex, marital status, medical diagnosis, social standing,
economic level, or religious belief.
65. Which situation reflects violation of the ethical
principle of veracity?
1. A nurse discusses with a client another client’s
impending discharge.
2. A nurse refuses to give information to a physician
who is not responsible for the client’s care.
3. A nurse tricks a client into seclusion by asking
the client to carry linen to the seclusion room.
4. A nurse does not treat all of the clients equally,
regardless of illness severity.
ANS: 3
Rationale: The nurse who tricks a client into
seclusion has violated the ethical principle of veracity. The principle of
veracity refers to one’s duty to always be truthful and not intentionally
deceive or mislead clients.
66. A client who will be receiving electroconvulsive
therapy (ECT) must provide informed consent. Which situation should cause a
nurse to question the validity of the informed consent?
1. The client is paranoid.
2. The client is 87 years old.
3. The client incorrectly reports his or her spouse’s
name, date, and time of day.
4. The client relies on his or her spouse to interpret
the information.
ANS: 3
Rationale: The nurse should question the validity of
informed consent when the client incorrectly reports the spouse’s name, date,
and time of day. This indicates that this client is disoriented and may not be
competent to make informed choices.
67. A client diagnosed with schizophrenia receives
fluphenazine decanoate (Prolixin Decanoate) from a home health nurse. The
client refuses medication at one regularly scheduled home visit. Which nursing
intervention is ethically appropriate?
1. Allow the client to decline the medication and
document the decision.
2. Tell the client that if the medication is refused,
hospitalization will occur.
3. Arrange with a relative to add the medication to
the client’s morning orange juice.
4. Call for help to hold the client down while the
injection is administered.
ANS: 1
Rationale: It is ethically appropriate for the nurse
to allow the client to decline the medication and provide accurate
documentation. The client’s right to refuse treatment should be upheld, unless
the refusal puts the client or others in harm’s way.
68. Which situation exemplifies both assault and
battery?
1. The nurse becomes angry, calls the client offensive
names, and withholds treatment.
2. The nurse threatens to “tie down” the client and
then does so, against the client’s wishes.
3. The nurse hides the client’s clothes and medicates
the client to prevent elopement.
4. The nurse restrains the client without just cause
and communicates this to family.
ANS: 2
Rationale: The nurse in this situation has committed
both the acts of assault and battery. Assault refers to an action that results
in fear and apprehension that the person will be touched without consent.
Battery is the touching of another person without consent.
69. A geriatric client is confused and wandering in
and out of every door. Which scenario reflects the least restrictive
alternative for this client?
1. The client is placed in seclusion.
2. The client is placed in a geriatric chair with
tray.
3. The client is placed in soft Posey restraints.
4. The client is monitored by an ankle bracelet.
ANS: 4
Rationale: The least-restrictive alternative for this
client would be monitoring by an ankle bracelet. The client does not pose a
direct dangerous threat to self or others, so neither physical restraints nor
seclusion would be justified.
70. A brother calls to speak to his sister, who has
been admitted to a psychiatric unit. The nurse connects him to the community
phone, and the sister is summoned. Later the nurse realizes that the brother
was not on the client’s approved call list. What law has the nurse broken?
1. The National Alliance for the Mentally Ill Act
2. The Tarasoff Ruling
3. The Health Insurance Portability and Accountability
Act
4. The Good Samaritan Law
ANS: 3
Rationale: The nurse has violated the Health Insurance
Portability and Accountability Act (HIPAA) by revealing that the client had
been admitted to the psychiatric unit. The nurse should not have provided any
information without proper consent from the client.
71. After disturbing the peace, an aggressive,
disoriented, unkempt, homeless individual is escorted to an emergency department.
The client threatens suicide. Which of the following criteria would enable a
physician to consider involuntary commitment? (Select all that apply.)
1. Being dangerous to others
2. Being homeless
3. Being disruptive to the community
4. Being gravely disabled and unable to meet basic
needs
5. Being suicidal
ANS: 1, 4, 5
Rationale: The physician could consider involuntary
commitment when a client is dangerous to others, gravely disabled, or is
suicidal. If the physician determines that the client is mentally incompetent,
consent should be obtained from the legal guardian or court-approved guardian
or conservator. A hospital administrator may give permission for involuntary
commitment when time does not permit court intervention.
72. An African American youth, growing up in an
impoverished neighborhood, seeks affiliation with a black gang. Soon he is
engaging in theft and assault. What cultural consideration should a nurse
identify as playing a role in this youth’s choices?
1. Most African American homes are headed by strong,
dominant father figures.
2. Most African Americans choose to remain within
their own social organization.
3. Most African Americans are uncomfortable expressing
emotions and seek out belonging.
4. Most African Americans have few religious beliefs,
which contributes to criminal activity.
ANS: 2
Rationale: The nurse should identify that a tendency
to remain within one’s own social organization may have played a role in the
youth’s choice to join a black gang. African Americans who have assimilated
into the dominant culture are likely to be well educated and future focused.
Those who have not assimilated may be unemployed or have low-paying jobs and
view their future as hopeless, given their previous encounters with racism and
discrimination.
73. Northern European Americans value punctuality,
hard work, and the acquisition of material possessions and status. A nurse
should recognize that these values may contribute to which form of
psychopathology?
1. Dissociative disorders
2. Alzheimer’s dementia
3. Stress-related disorders
4. Schizophrenia-spectrum disorders
ANS: 3
Rationale: The nurse should correlate many Northern
European American values, such as punctuality, hard work, and acquisition of
material possessions, with stress-related disorders. Psychopathology may occur
when individuals fail to meet the expectations of the culture.
74. A community health nurse is planning a health fair
at a local shopping mall. Which middle-class socioeconomic cultural group
should the nurse anticipate would most value preventive medicine and primary
health care?
1. Northern European Americans
2. Native Americans
3. Latino Americans
4. African Americans
ANS: 1
Rationale: The community health nurse should
anticipate that Northern European Americans, especially those who achieve
middle-class socioeconomic status, place the most value on preventative
medicine and primary health care. This value is most likely related to this
group’s educational level and financial capability. Many members of the Native American,
Latino American, and African American subgroups value folk medicine practices.
75. Which rationale by a nursing instructor best
explains why it is challenging to globally classify the Asian American culture?
1. Extremes of emotional expression prevent accurate
assessment of this culture.
2. Suspicion of Western civilization has
understandably resulted in minimal participation in cultural research.
3. The small size of this subpopulation makes research
virtually impossible.
4. The Asian American culture includes individuals
from Japan, China, Vietnam, Korea, and other countries.
ANS: 4
Rationale: The nursing instructor’s best explanation
is that the Asian American culture is difficult to classify globally because of
the number of countries that identify with this culture. The Asian American
culture includes peoples and descendents from Japan, China, Vietnam, the
Philippines, Thailand, Cambodia, Korea, Laos, India, and the Pacific Islands.
Within this culture there are vast differences in values, religious practices,
languages, and attitudes.
76. A Latin American woman refuses to participate in
an assertiveness training group. Which cultural belief should a nurse identify
as most likely to affect this client’s decision?
1. Future orientation causes the client to devalue
assertiveness skills.
2. Decreased emotional expression makes it difficult
to be assertive.
3. Assertiveness techniques may not be aligned with
the client’s definition of the female role.
4. Religious prohibitions prevent the client’s
participation in assertiveness training.
ANS: 3
Rationale: The nurse should identify that the Latin
American woman’s refusal to participate in an assertiveness training group may
be affected by the Latin American cultural definition of the female role. Latin
Americans place a high value on the family, which is male dominated. The father
usually possesses the ultimate authority.
77. A Latin American man refuses to acknowledge
responsibility for hitting his wife, stating instead, “It’s the man’s job to
keep his wife in line.” Which cultural belief should a nurse associate with
this client’s behavior?
1. That families are male–dominated, with clear
male-female role distinctions.
2. That religious tenets support the use of violence
in a marital context.
3. That the nuclear family is female-dominated and the
mother has ultimate authority.
4. That marriage dynamics are controlled by dominant
females in the family.
ANS: 1
Rationale: The nurse should associate the cultural
belief that families are male–dominated, with clear male-female role
distinctions with the client’s abusive behavior. The father in the Latin
American family usually has the ultimate authority.
78. When working with clients of a particular culture,
which action should a nurse avoid?
1. Making direct eye contact
2. Assuming that all individuals who share a culture
or ethnic group are similar
3. Supporting the client in participating in cultural
and spiritual rituals
4. Using an interpreter to clarify communication
ANS: 2
Rationale: The nurse should avoid assuming that all
individuals who share a culture or ethnic group are similar. This action
constitutes stereotyping and must be avoided. Within each culture, many
variations and subcultures exist. Clients should be treated as individuals.
79. To effectively plan care for Asian American
clients, a nurse should be aware of which cultural factor?
1. Obesity and alcoholism are common problems.
2. Older people maintain positions of authority within
the culture.
3. “Tai” and “chi” are the fundamental concepts of
Asian health practices.
4. Asian Americans are likely to seek psychiatric
help.
ANS: 2
Rationale: To effectively care for Asian American
clients, the nurse should be aware that older people in this culture maintain
positions of authority. Obesity and alcoholism are low among Asian Americans.
The balance of yin and yang is the fundamental concept of Asian health
practices. Psychiatric illness is often believed to be out-of-control behavior
and would be considered shameful to individuals and families.
80. A Native American client is admitted to an
emergency department (ED) with an ulcerated toe, secondary to uncontrolled
diabetes mellitus. The client refuses to talk to a physician unless a shaman is
present. Which nursing intervention is most appropriate?
1. Try to locate a shaman that will agree to come to
the ED.
2. Explain to the client that “voodoo” medicine will
not heal the ulcerated toe.
3. Ask the client to explain what the shaman can do
that the physician cannot.
4. Inform the client that refusing treatment is a
client’s right.
ANS: 1
Rationale: The most appropriate nursing intervention
would be to try to locate a shaman that will agree to come to the ED. The nurse
should understand that in the Native American culture, religion, and
health-care practices are often intertwined. The shaman, a medicine man, may
confer with physicians regarding the care of a client. Research supports the
importance of both health-care systems in the overall wellness of Native
American clients.
81. When planning client care, which folk belief that
may affect health-care practices should a nurse identify as characteristic of
the Latino American culture?
1. The root doctor is often the first contact made
when illness is encountered.
2. The yin and yang practitioner is often the first
contact made when illness is encountered.
3. The shaman is often the first contact made when
illness is encountered.
4. The curandero is often the first contact made when
illness is encountered.
ANS: 4
Rationale: The nurse should understand that it is
characteristic of Latin American culture for a client to contact a curandero
when illness is initially encountered. The curandero is the folk healer who is
believed to have a gift from God for healing the sick. Treatments often include
supernatural rituals, prayers, magic, practical advice, and indigenous herbs.
82. In what probable way should a nurse expect an
Asian American client to view mental illness?
1. Mental illness relates to uncontrolled behaviors
that bring shame to the family.
2. Mental illness is a curse from God related to
immoral behaviors.
3. Mental illness is cured by home remedies based on
superstitions.
4. Mental illness is cured by “hot and cold” herbal
remedies.
ANS: 1
Rationale: The nurse should except that many Asian
Americans are most likely to view mental illness as uncontrolled behavior that
brings shame to the family. In addition, it is often more acceptable for mental
distress to be expressed as physical ailments.
83. Which cultural considerations should a nurse
identify as reflective of Western European Americans?
1. They are present-time oriented and perceive the
future as God’s will.
2. They value youth, and older adults are commonly
placed in nursing homes.
3. They are at high risk for alcoholism, because of a
genetic predisposition.
4. They are future oriented and practice preventive
health care.
ANS: 1
Rationale: The nurse should identify that most Western
European Americans are present oriented and perceive the future as God’s will.
Older adults are held in positions of respect and are often cared for in the
home instead of in nursing homes.
84. A nurse should recognize that clients who have a
history of missed or late medical appointments are most likely to come from
which cultural group?
1. African Americans
2. Asian Americans
3. Native Americans
4. Jewish Americans
ANS: 3
Rationale: The nurse should recognize that Native
American clients might have a history of missed or late medical appointments.
Many Native Americans are not ruled by the clock. The concept of time is casual
and focused on the present.
85. When interviewing a client of a different culture,
which of the following questions should a nurse consider? (Select all that
apply.)
1. Would using perfume products be acceptable?
2. Who may be expected to be present during the client
interview?
3. Should communication patterns be modified to
accommodate this client?
4. How much eye contact should be made with the
client?
5. Would hand shaking be acceptable?
ANS: 2, 3, 4, 5
Rationale: When interviewing a client from a different
culture, the nurse should consider who might be with the client during the
interview, modifications of communication patterns, amount of eye contact, and
hand-shaking acceptability. Given that cultural influences affect human
behavior, its interpretation, and another person’s response, it is important
for nurses to understand the effects of these cultural influences to work
effectively with diverse populations.
86. A female nurse is caring for an Arab American male
client. When planning effective care for this client, the nurse should be aware
of which of the following cultural considerations? (Select all that apply.)
1. Limited touch is acceptable only between members of
the same sex.
2. Conversing individuals of this culture stand far
apart and do not make eye contact.
3. Devout Muslim men may not shake hands with women.
4. The man is the head of the household, and women
take on a subordinate role.
5. Men of this culture are responsible for the
education of their children.
ANS: 1, 3, 4
Rationale: When planning effective care for this
client, the nurse should be aware that limited touch in this culture is
acceptable only between members of the same sex, that devout Muslim men may not
shake hands with women, and that women are subordinate to the man, who is the
head of household. Conversing individuals of this culture stand close together
and maintain eye contact. Arab American women are responsible for the education
of children.
87. In which of the following cultural groups should a
nurse expect to find assessment of mood and affect most challenging, owing to
the characteristics of the groups? (Select all that apply.)
1. Arab Americans
2. Native Americans
3. Latino Americans
4. Western European Americans
5. Asian Americans
ANS: 2, 5
Rationale: The nurse should expect that both Native
Americans and Asian Americans may be difficult to assess for mood and affect.
In both cultures, expressing emotions is difficult. Native Americans are
encouraged to not communicate private thoughts. Asian Americans may have a
reserved public demeanor and may be perceived as shy or uninterested.
88. A nursing instructor is developing a lesson plan
to teach about the Northern European American culture. Which of the following
information should be included? (Select all that apply.)
1. About half of first marriages end in divorce in
this cultural group.
2. This cultural group does not use preventive
medicine and primary health care.
3. Punctuality and efficiency are highly valued in
this cultural group.
4. This cultural group tends to be future oriented.
5. A typical diet of this cultural group includes
rice, vegetables, and fish.
ANS: 1, 3, 4
Rationale: With the advent of technology and
widespread mobility, less emphasis has been placed on the cohesiveness of the
family in the Northern European American culture. Data on marriage, divorce,
and remarriage in the United States show that about half of first marriages end
in divorce. Northern European Americans, particularly those who achieve
middle-class socioeconomic status, value preventive medicine and primary health
care. Punctuality and efficiency are highly valued in the culture that promoted
the work ethic, and most within this cultural group tend to be future oriented.
A typical diet for many Northern European Americans is high in fats and
cholesterol and low in fiber.
89. The United States, viewed as a “melting pot” of
multiple worldwide ethnic groups, has its own unique culture that impacts the
health and care of individuals. Which of the following are characteristics
common to the U.S. culture? (Select all that apply.)
1. The culture values independence, self-reliance, and
determining one’s life.
2. There is a strong emphasis on achievement in jobs,
sports, and physical beauty.
3. Constructive criticism is considered personally
offensive.
4. The culture favors structured and formal behaviors,
speech, and relationships with others.
5. Overconsumption of food in this culture leads to
increased obesity and decreased health.
ANS: 1, 2, 5
Rationale: Independence, self reliance, and
determining one’s life describes the characteristic of individuality. Strong
emphasis on achievement in jobs, sports, and physical beauty describes the
characteristic of perfectionism. Constructive criticism is considered helpful
for others in the U.S. culture. General behaviors, speech, and relationships
with others are informal. There is common use of first names when addressing others.
The overconsumption of food, leading to increased obesity and decreased health
relates to the characteristic of consumerism.
90. What is the most essential task for a nurse to
accomplish prior to forming a therapeutic relationship with a client?
1. Clarify personal attitudes, values, and beliefs.
2. Obtain thorough assessment data.
3. Determine the client’s length of stay.
4. Establish personal goals for the interaction.
ANS: 1
Rationale: The most essential task for a nurse to
accomplish prior to forming a therapeutic relationship with a client is to
clarify personal attitudes, values, and beliefs. Understanding one’s own
attitudes, values, and beliefs is called self-awareness.
91. If a client demonstrates transference toward a
nurse, how should the nurse respond?
1. Promote safety and immediately terminate the
relationship with the client.
2. Encourage the client to ignore these thoughts and
feelings.
3. Immediately reassign the client to another staff
member.
4. Help the client to clarify the meaning of the
relationship, based on the present situation
ANS: 4
Rationale: The nurse should respond to a client’s
transference by clarifying the meaning of the nurse-client relationship based
on the present situation. Transference occurs when the client unconsciously
displaces feelings about a person from the past toward the nurse. The nurse
should assist the client in separating the past from the present.
92. What should be the priority nursing action during
the orientation (introductory) phase of the nurse-client relationship?
1. Acknowledge the client’s actions and generate
alternative behaviors.
2. Establish rapport and develop treatment goals.
3. Attempt to find alternative placement.
4. Explore how thoughts and feelings about this client
may adversely impact nursing care.
ANS: 2
Rationale: The priority nursing action during the
orientation phase of the nurse-client relationship should be to establish
rapport and develop treatment goals. Rapport implies feelings on the part of
both the nurse and the client, based on respect, acceptance, a sense of trust,
and a nonjudgmental attitude. It is the essential foundation of the
nurse-client relationship.
93. Which client action should a nurse expect during
the working phase of the nurse-client relationship?
1. The client gains insight and incorporates
alternative behaviors.
2. The client establishes rapport with the nurse and
mutually develops treatment goals.
3. The client explores feelings related to reentering
the community.
4. The client explores personal strengths and
weaknesses that impact behavioral choices.
ANS: 1
Rationale: The nurse should expect that that the
client will gain insight and incorporate alternative behaviors during the
working phase of the nurse-client relationship. The client may also overcome
resistance, problem-solve, and continually evaluate progress toward goals.
94.Which client statement should a nurse identify as a
typical response to stress most often experienced in the working phase of the
nurse-client relationship?
1. “I can’t bear the thought of leaving here and
failing.”
2. “I might have a hard time working with you, because
you remind me of my mother.”
3. “I really don’t want to talk any more about my
childhood abuse.”
4. “I’m not sure that I can count on you to protect my
confidentiality.”
ANS: 3
Rationale: The nurse should identify that the client
statement, “I really don’t want to talk any more about my childhood abuse,”
reflects that the client is in the working phase of the nurse-client
relationship. The working phase includes overcoming resistance behaviors on the
part of the client as the level of anxiety rises in response to discussion of
painful issues.
95. A mother who is notified that her child was killed
in a tragic car accident states, “I can’t bear to go on with my life.” Which
nursing statement conveys empathy?
1. “This situation is very sad, but time is a great
healer.”
2. “You are sad, but you must be strong for your other
children.”
3. “Once you cry it all out, things will seem so much
better.”
4. “It must be horrible to lose a child, and I’ll stay
with you until your husband arrives.”
ANS: 4
Rationale: The nurse’s response, “It must be horrible
to lose a child, and I’ll stay with you until your husband arrives,” conveys
empathy to the client. Empathy is the ability to see the situation from the
client’s point of view. Empathy is considered to be one of the most important
characteristics of the therapeutic relationship.
96. When an individual is “two-faced,” which
characteristic essential to the development of a therapeutic relationship
should a nurse identify as missing?
1. Respect
2. Genuineness
3. Sympathy
4. Rapport
ANS: 2
Rationale: When an individual is “two-faced,” which
means double-dealing or deceitful, the nurse should identify that genuineness
is missing in the relationship. Genuineness refers to the nurse’s ability to be
open and honest and maintain congruence between what is felt and what is
communicated. When a nurse fails to bring genuineness to the relationship,
trust cannot be established.
97. On which task should a nurse place priority during
the working phase of relationship development?
1. Establishing a contract for intervention
2. Examining feelings about working with a particular
client
3. Establishing a plan for continuing aftercare
4. Promoting the client’s insight and perception of
reality
ANS: 4
Rationale: The nurse should place priority on
promoting the client’s insight and perception of reality during the working
phase of relationship development. Establishing a contract for intervention
would occur in the orientation phase. Examining feelings about working with a
client should occur in the pre-interaction phase. Establishing a plan for
aftercare would occur in the termination phase.
98. Which therapeutic communication technique is being
used in the following nurse-client interaction?
Client: “My father spanked me often.”
Nurse: “Your father was a harsh disciplinarian.”
1. Restatement
2. Offering general leads
3. Focusing
4. Accepting
ANS: 1
Rationale: The nurse is using the therapeutic
communication technique of restatement. Restatement involves repeating the main
idea of what the client has said. It allows the client to know whether the
statement has been understood and provides an opportunity to continue.
99. Which therapeutic communication technique is being
used in the following nurse-client interaction?
Client: “When I am anxious, the only thing that calms
me down is alcohol.”
Nurse: “Other than drinking, what alternatives have
you explored to decrease anxiety?”
1. Reflecting
2. Making observations
3. Formulating a plan of action
4. Giving recognition
ANS: 3
Rationale: The nurse is using the therapeutic
communication technique of formulating a plan of action to help the client
explore alternatives to drinking. The use of this technique may serve to
prevent anger or anxiety from escalating.
100. The nurse is interviewing a newly admitted
psychiatric client. Which of the following nursing statements is an example of
offering a “general lead”?
1. “Do you know why you are here?”
2. “Are you feeling depressed or anxious?”
3. “Yes, I see. Go on.”
4. “Can you order the specific events that led to your
admission?”
ANS: 3
Rationale: The nurse’s statement, “Yes, I see. Go on,”
is an example of a general lead. Offering general leads encourages the client
to continue sharing information.
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