NCLEX Reviewers » Psychiatric Nursing

Psychiatric Nursing NCLEX Review Part 2 Answers and Rationale

admin — Mon, 08 Feb 2010 00:15:39 +0000

Answer B. Diphenhydramine, 25 to 50 mg I.M. or I.V., would quickly reverse this condition. Prochlorperazine and haloperidol are both capable of causing dystonia, not reversing it. Midazolam would make this patient drowsy.
Answer B. The nurse should directly orient a delusional patient to reality, especially to place and person. Option A and C encourage further delusions by denying poisoning and offering information related to the delusion. Validating the patient’s feeling, as in option D, occurs during a later stage in the therapeutic process.
Answer C. Twelve-step programs focus on recovery 1 day at a time. Such programs discourage people from claiming that they will never again use a substance, because relapse is common. The belief that one may use a limit amount of an abused substance indicates denial. Substituting one abused substance for another predisposes the patient to cross-addiction.
Answer B. By establishing a one-to-one relationship, the nurse helps the patient learn how to interact with other people in new situations. The other options are appropriate but should take place only after the nurse-patient relationship is established.
Answer D. A compulsion is a repetitive act or impulse helps a person to reduce anxiety unconsciously. An obsessive-compulsive patient does not want to call attention to self and cannot control thoughts. This patient’s priority is to reduce anxiety, not maintain the safety of the home.
Answer A. By acknowledging how the patient feels, this response encourages further expression of thoughts and feelings. Minimizing feelings or offering empty reassurances is not therapeutic or helpful. Deep breathing or preoperative medication would be appropriate only after the patient’s fears have been expressed and dealt with.
Answer C. The nurse must determine whether the restraints have been applied correctly to make sure that patient’s circulation and respiration are not restricted and that adequate padding has been used. The nurse should document the patient’s response and status carefully after the restraints are applied. All staff members involved in restraining patients should be aware of hospital policy before using restraints. If p.r.n. medication is ordered, it should be given before the restraints are in place and with the assistance of other team members. The nurse should attend to the patient’s elimination and hydration needs after the patient is properly restrained.
Answer D. Although most phenothiazine produce some effects within minutes to hours, their antipsychotic effects may take several weeks to appear.
Answer C. Most states allow restraints to be used if the patient presents a danger to self or others. This danger must be reevaluated every few hours. If the patient is still a danger, restraints can be used until the violent behavior abates. No standing orders for restraints are allowed, and restraints are permitted only until more “humane” methods, such as sedatives, become more effective. Violent patients who are intoxicated with drugs or alcohol present a problem because they rarely can be sedated until the drug or alcohol is metabolized. In such cases, restraints may be needed for a longer period, but the patient must be closely observed. Obtaining consent is not always possible, especially when the patient’s violent behavior results from a psychosis, such as paranoid schizophrenia.
Answer C. Conditions requiring cautious use of amitriptyline include pregnancy, lactation, suicidal tendencies, cardiovascular disease, and impaired hepatic function. Hiatal hernia, hypernatremia, and hypokalemia do not affect amitriptyline therapy.
Answer B. Providing an opportunity for the client to express concern about a new medication and to make a choice about taking it can help the client regain a sense of control over his life. The client has the right to refuse the medication. Instead of simply ordering the client to take it, as in option 1, the nurse should provide the information the client needs to make an informed decision. Attempting to make the client feel guilty, as in option 3, or threatening the client, as option 4, would increase anxiety.
Answer A. Decreased libido, retrograde ejaculation, and gynecomastia are all hormonal effects that can occur with antipsychotic medications. Reassure the client that the effects can be reversed or that changing medication may be possible. Polydipsia, akinesia, and dysphasia aren’t hormonal effects.
Answer A. Anxiety is a normal reaction to the termination of the nurse-client relationship. The nurse should help the client explore his feelings about the end of the therapeutic relationship. While anger about the termination may be a healthy response, banging the table, shouting, and other forms of acting out aren’t appropriate behavior. Withdrawal isn’t a healthy response to the termination of a relationship. By rationalizing the termination, the client avoids expressing his feelings and emotions.
Answer A. The client with schizophrenia is commonly socially isolated and withdrawn; therefore, having the client spend more time by himself wouldn’t be a desirable outcome. Rather, a desirable outcome would specify that the client spend more time with other clients and staff on the unit. Delusions are false personal beliefs. Reducing or eliminating delusional thinking using talking therapy and antipsychotic medications would be a desirable outcome. Protecting the client and others from harm is a desirable client outcome achieved by close observation, removing any dangerous objects, and administering medications. Because the client with schizophrenia may have difficulty meeting his or her own self-care needs, fostering the ability to perform self-care independently is a desirable client outcome.
Answer A. Because a client who has attempted suicide could try again, the nurse should search the client’s belongings and room to remove any items that could be used in another suicide attempt. Expressing trust that the client won’t cause self-harm may increase guilt and pain if the client can’t live up to that trust. The nurse should search the client’s belonging because the need to maintain a safe environment supersedes the client’s right to privacy. Although frequent checks by staff members are helpful, they aren’t enough because the client may attempt suicide between checks.
Answer C. Displacement is a defense mechanism in which the client transfers his feelings for one person toward another person who is less threatening. Rationalization is a defense mechanism in which the client makes excuses to justify unacceptable feeling or behaviors. Repression is characterized by an involuntary blocking of unpleasant experiences from one’s consciousness. Suppression is the conscious blocking of unpleasant experiences form one’s awareness.
Answer C. The nurse should prepare a client for ECT in a manner similar to that for general anesthesia. For example, the client should receive nothing by mouth for 8 hours before ECT to reduce the risk of vomiting and aspiration. Also, the nurse should have the client void before treatment to decrease the risk of involuntary voiding during the procedure, remove any full denture, glasses, or jewelry to prevent breakage or loss; and make sure the client is wearing a hospital gown or loose-fitting clothing to allow unrestricted movement. Usually, these preparations aren’t indicated for a client undergoing physical therapy, neurologic examination, or cardiac stress testing.
Answer D. A flexible care plan needed for any client who behaves in a suspicious, withdrawn, or regressed manner or who has thought disorder. Because such a client communicates at different levels and is in control of himself at various times, the nurse must be able to adjust nursing care as the situation warrants. The nurse’s role should be clear, however, the boundaries or limits of this role should be flexible enough to meet client needs. Because a client with schizophrenia fears closeness and affection, a warm approach may be too threatening. Expressing empathy is important, but centering interventions on clear defined limits is impossible because the client’s situation may change without warning.
Answer D. When caring for a client with OCD, the goal is to systematically decrease the undesirable behavior. (Therapy may not completely extinguish certain behaviors.) Expecting to omit one behavior each day is unrealistic because the client may have used ritualistic behavior would perpetuate the undesirable behavior.
Answer D. Fluphenazine decanoate is a long-acting antipsychotic agent given by injection. Because it has a 4-week duration of action, it’s commonly prescribed for outpatients with a history of medication noncompliance. Chlorpromazine, also an antipsychotic agent, must be administered daily to maintain adequate plasma levels, which necessitates compliance with the dosage schedule. Imipramine, a tricyclic antidepressant, and lithium carbonate, a mood stabilizer, are rarely used to treat clients with chronic schizophrenia.
Answer A. Individuals with dependent personality disorder typically shows indecisiveness, submissiveness, and clinging behavior so that others will make decisions for them. These clients feel helpless and uncomfortable when alone and don’t show interest in solitary activities. They also pursue relationships in order to have someone to take care of them. Although clients with dependent personality disorder may become depressed and suicidal if their needs aren’t met, this isn’t a typical response.
Answer C. Abstract thinking is the ability to conceptualize and interpret meaning. It’s higher level of intellectual functioning than concrete thinking, in which the client explains the proverb by its literal meaning. Rational thinking involves the ability to think logically, make judgments, and be goal-directed. Tangential thinking is scattered, non-goal-directed, and hard to follow. Clients with such conditions as organic brain disease and schizophrenia typically can’t conceptualize and comprehend abstract meaning. They interpret such statement as “Don’t cry over spilled milk” in a literal sense, such as “Even if you spill your milk, you shouldn’t cry about it.”
Answer D. Although all these options may apply to this client, safety is the nurse’s first priority in caring for any suicidal client. The nurse can address the client’s hopelessness, ineffective coping, and spiritual distress later in therapy.
Answer A. Focusing on the client’s blindness can positively reinforce the blindness and further promote the use of maladaptive behaviors to obtain secondary gains. The client should be encouraged to participate in his own care as much as possible to avoid fostering dependency. To promote self-esteem, give positive reinforcement for what the client can do. Blindness and other physical symptoms in a conversion disorder aren’t under the client’s control and are real to him. Eye exercises won’t resolve the client’s blindness because no organic pathology is causing the symptoms.
Answer D. The aggressor is negative and hostile and uses sarcasm to degrade others. The role of the blocker is to resist group efforts. The monopolizer controls the group by dominating conversations. The recognition seeker talks about accomplishments to gain attention.
Answer C. Circulation as well as skin and nerve damage can occur within 15 minutes. Checking every hour, 2 hours, or 8 hours isn’t often enough and could result in permanent damage to the client’s extremities. Restraints should be removed every 2 hours, and range-of-motion exercises should be performed.
Answer A. When the child’s injuries are inconsistent with the history given or impossible because of the child’s age and developmental stage, the emergency department nurse should be suspicious that child abuse is occurring. The parents may tell different stories because their perception may be different regarding what happened. If they change their story when different health care workers ask the same question, this is a clue that child abuse may be a problem. Child abuse occurs in all socioeconomic groups. Parent may argue and be demanding because of the stress of having an injured child.
Answer C. Abuse and neglect lead to poor self-concept and confusion, the basis for unhealthy personal boundaries. Healthy boundaries are established in childhood when parent provide consistent, supportive limits and attention.
Answer D. This client requires a vasodilation such as nifedipine to treat hypertension, and a beta-adrenergic blocker such as esmolol to reduce the heart rate. Lidocaine, an antirrhythmic, isn’t indicated because the client doesn’t have an arrhythmia. Although nitrolycerin may be used to treat coronary vasospasm, it isn’t the drug of choice in hypertension.
Answer A. A structured lifestyle demonstrates acceptance and caring provides a sense of security. A critical environment erodes a person’s esteem. Inconsistent boundaries lead to feelings of insecurity and lack of concern. Physical discipline can decrease self-esteem.

Psychiatric Nursing NCLEX Review Part 1 Answers and Rationale Share this on Facebook Tweet This! Email this via...
Answers and Rationale of NCLEX Sample Questions for Psychiatric Nursing 4 Share this on Facebook Tweet This! Email this via...
Answers and Rationale Psychiatric Nursing Practice Test I Share this on Facebook Tweet This! Email this via...

Psychiatric Nursing NCLEX Review Part 2

admin — Thu, 04 Feb 2010 07:21:26 +0000

1. Which of the following medications would the nurse in-charge expect the doctor to order to reverse a dystonic reaction?

a. Procholorperazine (Compazine)

b. Diphenhydramine (Benadryl)

c. Haloperidol (Haldol)

d. Midazolam (Versed)

2. While pacing in the hall, a female patient with paranoid schizophrenia runs to the nurse and says, “Why are you poisoning me? I know you work for central thought control! You can keep my thoughts. Give me back my soul!” how should the nurse respond?

a. “I’m a nurse, I’m not poisoning you. It’s against the nursing code of ethics.”

b. “I’m a nurse, and you’re a patient in the hospital. I’m not going to harm you.”

c. “I’m not poisoning you. And how could I possibly steal your soul?”

d. “I sense anger, Are you feeling angry today?”

3. After completing chemical detoxification and a 12-step program to treat crack addiction, a male patient is being prepared for discharge. Which remark by the patient indicates a realistic view of the future?

a. “I’m never going to use crack again.”

b. “I know what I have to do. I have to limit my crack use.”

c. “I’m going to take 1 day at a time. I’m not making any promises.”

d. “I can’t touch crack again, but I sure could use a drink. I’ve earned it.”

4. The nurse formulates a nursing diagnosis of “impaired verbal communication” for a male patient with schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention is most appropriate?

a. Helping the patient to participate in social interactions

b. Establishing a one-on-one relationship with the patient

c. Establishing alternative forms of communication

d. Allowing the patient to decide when he wants to participate in verbal communication with you

5. A female patient with obsessive-compulsive disorder tells the nurse that he must check the lock on his apartment door 25 times before leaving for an appointment. The nurse knows that this behavior represents the patient’s attempt to:

a. Call attention to himself

b. Control his thoughts

c. Maintain the safety of his home

d. Reduce anxiety

6. A patient, age 42, is admitted for surgical biopsy of a suspicious lump in her left breast. When the nurse comes to her surgery, she is tearfully finishing a letter to her children. She tells the nurse, “I want to leave this for my children in case anything goes wrong today. “Which response by the nurse would be most therapeutic?

a. “In case anything goes wrong? What are your thoughts and feelings right now?”

b. “I can’t understand that you’re nervous, but this is really a minor procedure. You’ll be back in your room before you know it.”

c. “Try to take a few deep breaths and relax. I have some medication that will help.”

d. “I’m sure your children know how much you love them. You’ll be able to talk to them on the phone in a few hours.”

7. Which nursing intervention is most important when restraining a violent male patient?

a. Reviewing hospital policy regarding how long the patient can be restrained

b. Preparing a p.r.n. dose of the patient’s psychotropic medication

c. Checking that the restraints have been applied correctly

d. Asking if the patient needs to use the bathroom or is thirsty

8. How soon after chlorpromazine administration should the nurse in charge expect to see a patient’s delusion thoughts and hallucinations eliminated?

a. Several minutes

b. Several hours

c. Several days

d. Several weeks

9. Mental health laws in each state specify when restraints can be used and which type of restraints are allowed. Most laws stipulate that restraints can be used:

a. For a maximum of 2 hours

b. As necessary to control the patient

c. If the patient poses a present danger to self or others

d. Only with the patient’s consent

10. A female patient has been severely depressed since her husband died 6 months ago. Her doctor prescribes amitriptyline hydrochloride (Elavil), 50 mg P.O. daily. Before administering amitriptyline, the nurse reviews the patient’s medical history. Which preexisting condition would require cautions use of this drug?

a. Hiatal hernia

b. Hypernatremia

c. Hepatic disease

d. Hypokalemia

11. The physician orders a new medication for a male client with generalized anxiety disorder. During medication teaching, which statement or question by the nurse would be most appropriate?

a. “Take this medication. It will reduce your anxiety.”

b. “Do you have any concern about taking the medication?”

c. “Trust us. This medication has helped many people. We wouldn’t have you take it if it were dangerous.”

d. “How can we help you if you won’t cooperate?”

12. The nurse is aware that the Hormonal effects of the antipsychotic medications include which of the following?

a. Retrograde ejaculation and gynecomastia

b. Dysmenorrhea and increased vaginal bleeding

c. Polydipsia and dysmenorrheal

d. Akinesia and dysphasia

13. The nurse is caring for a female client in the manic phase of bipolar disorder who’s ready for discharge from the psychiatric unit. As the nurse begins to terminate the nurse-client relationship, which client response is most appropriate?

a. Expressing feeling of anxiety

b. Displaying anger, shouting, and banging the table

c. Withdrawing from the nurse in silence

d. Rationalizing the termination, saying that “everything comes to an end”

14. The nurse is caring for a male client with schizophrenia. Which outcome is the least desirable?

a. The client spends more time by himself

b. The client doesn’t engage in delusional thinking

c. The client doesn’t harm himself or others

d. The client demonstrates the ability to meet his own self-care needs

15. The nurse is assigned to care for a recently admitted female client who has attempted suicide. What should the nurse do?

a. Search the client’s belongings and room carefully for items that could be used to attempt suicide

b. Express trust that the client won’t cause self-harm while in the facility

c. Respect the client’s privacy by not searching any belongings

d. Remind all staff members to check on the client frequently

16. A male client becomes angry and belligerent toward the nurse after speaking on the phone with his mother. The nurse recognizes this as what defense mechanism?

a. Rationalization

b. Repression

c. Displacement

d. Suppression

17. Nursing preparations for a client undergoing electroconvulsive therapy (ECT) resembles those used for:

a. Physical therapy

b. Neurologic examination

c. General anesthesia

d. Cardiac stress testing

18. Nursing care for a male client with schizophrenia must be based on valid psychiatric and nursing theories. The nurse’s interpersonal communication with the client and specific nursing intervention must be:

a. Clearly identified with boundaries and specifically defined roles

b. Warn and non threatening

c. Centered on clearly defined limits and expression of empathy

d. Flexible enough for the nurse to adjust the care plan as the situation warrants

19. Before eating a meal, a female client with obsessive-compulsive disorder (OCD) must wash his hands for 18 minutes, comb his hair 444 strokes, and switch the bathroom lights 44 times. What is the most appropriate goal of care for this client?

a. Omit one unacceptable behavior each day

b. Increase the client’s acceptance of therapeutic drug use

c. Allow ample time for the client to complete all rituals before each meal

d. Systematically decrease the number of repetitions of rituals and the amount of time spent performing them.

20. A male client with a history of medication noncompliance is receiving outpatient treatment for chronic undifferentiated schizophrenia. The physician is most likely to prescribe which medication for this client?

a. Chlorpromazine (Thorazine)

b. Imipramine (Tofranil)

c. Lithium carbonate (Lithane)

d. Fluphenazine decanoate (Prolixin Decanoate)

21. A 23-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely to be evidence of ineffective individual coping?

a. In ability to make choices and decisions without advice

b. Showing interest only in solitary activities

c. Avoiding developing relationship

d. Recurrent self-destructive behavior with history of depression

22. During the mental status examination, a female client may be asked to explain such proverbs as “Don’t cry over spilled milk.” The purpose is to evaluate the client’s ability to think:

a. Rationally

b. Concretely

c. Abstractly

d. Tangentially

23. After an upsetting divorce, a male client threatens to commit suicide with a handgun and is involuntarily admitted to the psychiatric unit with major depression. Which nursing diagnosis takes highest priority for this client?

a. Hopelessness related to recent divorce

b. Ineffective coping related to inadequate stress management

c. Spiritual distress related to conflicting thoughts about suicide and sin

d. Risk for self-directed-violence related to planning to commit suicide with a handgun

24. A 25-year-old man reports losing his sight in both eyes. He’s diagnosed as having conversion disorder and is admitted to the psychiatric unit. Which nursing intervention would be most appropriate for this client?

a. Not focusing on his blindness

b. Providing self-care for him

c. Telling him that his blindness isn’t real

d. Teaching eye exercises to strengthen his eyes

25. In group therapy, a male client angrily speaks up and responds to a peer, “You’re always whining and I’m getting tired of listening to you! Here is the world’s smallest violin playing for you.” Which role is the client playing?

a. Blocker

b. Monopolizer

c. Recognition seeker

d. Aggressor

26. A nurse places a female client in full leather restraints. How often must the nurse check the client’s circulation?

a. Once per hour

b. Once per shift

c. Every 10 to 15 minutes

d. Every 2 hours

27. When interviewing the parents of an injured child, which sign is the strongest indicator that child abuse may be a problem?

a. The injury isn’t consistent with the history of the child’s age

b. The mother and father tell different stories regarding what happened

c. The family is poor

d. The parents are argumentative and demanding with emergency department personnel

28. Unhealthy personal boundaries are a product of dysfunctional families and a lack of positive role models. Unhealthy boundaries may also be a result of:

a. Structured limit setting

b. Supportive environment

c. Abuse and neglect

d. Direction and attention

29. When monitoring a male client recently admitted for treatment of cocaine addiction, the nurse notes sudden increase in the arterial blood pressure and heart rate. To correct these problems, the nurse expects the physician to prescribe:

a. Norepinephrine (Levophed) and lidocaine (Xylocaine)

b. Nifedipine (Procardia) and lidocaine

c. Nitroglycerin (Nitro-Bid IV) and esmolol (Brevibloc)

d. Nifedipine and nitroglycerin

30. Conditions necessary for the development of a positive sense of self-esteem include:

a. Consistent limits

b. Critical environment

c. Inconsistent boundaries

d. Physical discipline

Answers and Rationale

Psychiatric Nursing NCLEX Review Part 1 Share this on Facebook Tweet This! Email this via...
Psychiatric Nursing NCLEX Review Part 2 Answers and Rationale Share this on Facebook Tweet This! Email this via...
Psychiatric Nursing NCLEX Review Part 1 Answers and Rationale Share this on Facebook Tweet This! Email this via...

Psychiatric Nursing NCLEX Review Part 1 Answers and Rationale

admin — Sun, 31 Jan 2010 02:17:22 +0000

View Questions

Answer A. As individuals become older, their livers metabolize drugs at a slower rate. Cumulative effects can occur and increase the risk of adverse reactions. Level of activity typically doesn’t affect a person’s reaction to medication. Elderly clients typically need lower doses, not higher.
Answer B. Stimulants produce mood swings, weight loss, and tachycardia. The other symptoms indicate CNS depression.
Answer B. A psychiatric aide can sit with the client and provide safety. The nurse is still responsible for assessing the client and ensuring that one-to-one supervision occurs. Aides are capable of providing one-to-one observation. It isn’t illegal to delegate observation to an aide.
Answer C. It’s extremely important that the nurse establish trust and rapport. The nurse shouldn’t offer advice. Instead, she should help the client develop the coping mechanisms necessary to solve his own problems. Setting limits is also important as developing trust and rapport.
Answer C. Abuse and neglect lead to poor self-concept and role confusion, which are the basis for unhealthy personal boundaries. Healthy boundaries are established in childhood when parents provide consistent, supportive environment, and direction and attention.
Answer C. The basic element of assertive behavior includes the ability to express feelings and thoughts while respecting the rights of others. Doing so at the expense of others and expressing superiority are aggressive behaviors, and avoiding unpleasant situation is a form of passive behavior.
Answer A. Asking the client to summarize his point redirects the clients to focus his comments and allows him to make his point. Telling the client that his behavior is obnoxious is judgmental, and ignoring the behavior doesn’t help facilitate communication. Expressing frustration focuses more on the nurse than on the client’s need.
Answer D. ECT is indicated for major depression. ECT isn’t indicated severe agitation, antisocial behavior, or treatment noncompliance.
Answer D. Breach of confidentiality occurs when a nurse shares information that can cause harm to an individual. Assault is an act that results in fear that one will be touched without consent.
Battery involves unconsented touching of another person. Neglect is the failure to do what’s deemed reasonable in a situation.
Answer B. The nurse violated confidentiality by informing the officer that the client wasn’t in treatment. Even with law enforcement agents, the nurse must be a client advocate and protect the client’s confidentiality. Because it’s unknown in this question whether the client is actually in treatment, it can’t be concluded that the nurse is misleading the officer because her statement may be truthful. Information can be legally withheld when a court order isn’t in place.
Answer D. The nurse’s release of information to the client’s employer without the client’s consent is a breach of confidentiality. The stigma associated with psychiatric illness may affect the client’s employment; therefore, it’s better to maintain confidentiality and refrain from disclosing any information about the client, including whether she’s a client in the hospital.
Answer A. Confining a voluntary client against his will be considered false imprisonment. Limit setting is a therapeutic technique used to achieve a desired behavior, and wouldn’t involve confining a voluntary client. Slander is oral defamation of character. The nurse hasn’t given out any information about the client, so confidentiality hasn’t been violated.
Answer C. The Nurse Practice Act outlines acceptable standards for nursing. Practicing within those guidelines will protect the nurse from liability. Physicians may not be aware of guidelines for nurses and may inadvertently delegate inappropriate treatment of practice for the nurse. The client doesn’t know standards of care and isn’t responsible for the nurse’s actions. Insurance won’t prevent a liability suit, but only assist the nurse if a suit would be filed.
Answer C. Circulatory as well as skin and nerve damage can occur within 15 minutes. Checking every hour, 2 hours, or 8 hours isn’t often enough and could result is permanent damage to the client’s extremities.
Answer C. One of the criteria for involuntary commitment is an emergency in which the client is a threat to himself or others, such as a man who threatens to kill his wife. A parent might have a child removed from the home because of neglect, but that doesn’t meet the criteria for involuntary commitment. Many individuals with schizophrenia can learn to live with hallucinations and delusions and don’t require hospitalization. To meet criteria for involuntary commitment, a depressed individual must have a suicide plan and be a direct threat to himself.
Answer D. To determine care plan for clients who are noncompliant with medications, the nurse should consult with the physician. Unless the client presents a danger to himself of others, medications can’t be forced on a client. A dose shouldn’t be omitted without first checking with the physician. Intentionally deceiving of misleading a client violates the therapeutic relationship.
Answer D. When working with a dying patient and his family, the nurse uses active listening to assess their feelings, coping skills, and immediate and long-term needs. It also helps the nurse select other appropriate strategies, such as reflection and clarification. Interpretation should be used sparingly to avoid making false interference or putting the client on the defensive.
Answer B. Tolerance occurs when the body requires higher doses of substances, such alcohol, opioids, or benzodiazepines, to achieve desired effect. Increased response indicates a need for less of a drug to achieve the same effects. Allergic reactions are autoimmune response to a particular drug or class of drugs. A client may be able to take, or tolerate, the same drug for an extended period; however this isn’t the definition of developing tolerance.
Answer B. The goal of crisis intervention is the resolution of an immediate problem. The client must learn to solve his own problems. Although some clients do enter long-term therapy or are admitted to an acute care facility, neither is the goal of crisis intervention.
Answer D. The nurse is using observation to give the client feedback about his behavior and attitude. A broad statement doesn’t give feedback to the client. The nurse didn’t reassure the client or ask him to explain his actions (clarifying).
Answer A. Firmness and consistency regarding rules are the hallmarks of a plan of care for a patient with a personality disorder. Isolation is inappropriate and would violate the patient’s rights. Power struggles should be avoided because the patient may try to manipulate people through them. Behavior modification usually fails because of staff inconsistency and patient manipulation.
Answer A. A liquid phenothiazine preparation will produce effects in 2 to 4 hours. The onset with tablet is unpredictable.
Answer B. An antiparkinsonian agent, such as amantadine, may be used to control pseudoparkinsonism, diphenhydramine or benztropine may be used to control other extrapyramidal effects.
Answer A. Physiological needs, particularly breathing, are the first priorities during a panic attack. Having the patient breathe deeply into a paper bag corrects hyperventilation; restoring a normal breathing pattern should relieve the patient’s other symptoms. Orientation usually is unnecessary because most patients respond to external control and reduce stimulation. During a panic attack, the patient is not likely to act out but may strike out if feeling threatened. An anxiolytic agent may be effective but is not the first priority.
Answer C. Family violence usually is a learned behavior begets violence, putting this couple at risk. Repeated slapping may indicate poor, not moderate, impulse control. Violent people commonly are jealous and possessive and feel insecure in their relationships.
Answer B. The therapeutic nurse-patient relationship consists of four phases: preinteraction, introduction or orientation, working and termination. During the working phase, the nurse and patient together evaluate and refine the goals established during the orientation phase, in addition, major therapeutic work takes place and insight is integrated into a plan of action. The orientation phase involves assessing the patient, formulating a contract, exploring feelings, and establishing expectation about relationship. During the termination phase, the nurse prepares the patient for separation and explores feelings about the end of the relationship.
Answer B. In adolescents, depression typically manifests as truancy, a change of friends, social withdrawal, and oppositional behavior. In adults, it usually produces helplessness, hopelessness, hypersomnolence, and anorexia. Drug use may lead to curfew breaking, stealing, truancy, and oppositional behavior. Adolescents normally display hypersomnelence, and obsession with body image, and valuing of peer’s opinions.
Answer D. During a panic attack, the nurse’s best approach is to orient the patient to what is happening and provide reassurance that the patient will not be left alone. The anxiety level is likely to increase and the panic attack is likely to continue—if the patient is told to calm down (as in option A), asked the reasons for the attack (as in option B), or left alone (as in option C).
Answer B. Conversion disorder, or hysterical neurosis, is characterized by alteration or loss of physical function with no physiological basis; the patient’s symptoms result from psychological conflict. For example, a patient may report blindness after having observed a distressing act. None of the other opinions causes conversion disorder.
Answer C. The patient is exhibiting the defense mechanism of regression—a return to behavior characteristic of an earlier developmental level. Dependent, attention—getting behavior is an attempt to relieve anxiety. Repression would manifest as ignoring the symptoms. Somatization is the channeling of anxiety into a preoccupation with physical complaints. Conversion involves transfer of a mental conflict into a physical symptom to relieve anxiety.

Psychiatric Nursing NCLEX Review Part 2 Answers and Rationale Share this on Facebook Tweet This! Email this via...
Psychiatric Nursing NCLEX Review Part 1 Share this on Facebook Tweet This! Email this via...
Answers and Rationale of NCLEX Sample Questions for Psychiatric Nursing 4 Share this on Facebook Tweet This! Email this via...

Psychiatric Nursing NCLEX Review Part 1

admin — Thu, 28 Jan 2010 06:04:40 +0000

1. Which statement describes how elderly clients react to medication?

a. At increased risk for adverse reactions

b. Tolerate medication better because they’re less active

c. Metabolize medications quickly

d. All of the above

2. Nursing interventions for a male client taking central nervous system (CNS) stimulants include monitoring the client for which condition?

a. Hyperpyrexia, slow pulse, and weight gain

b. Tachycardia, weight loss, and mood swings

c. Hypotension, weight gain, and listlessness

d. All of the above

3. The charge nurse in an acute care setting assigns to a male client, who’s on one-to-one suicide precautions, to a psychiatric aide. This assignment is considered:

a. Poor nursing practice because a registered nurse should work with this client

b. Reasonable nursing practice because one-to-one supervision requires the total attention of a staff member

c. Outside the responsibility of an aide

d. Illegal to delegate to an aide

4. What’s a nurse most important role in caring for an adult client with a mental disorder?

a. To offer advice

b. To know how to solve the client’s problem

c. To establish trust and rapport

d. To set limits with the client

5. Unhealthy personal boundaries are a product of dysfunctional families and a lack of positive role models. Unhealthy boundaries may also be a result of:

a. Structured limit setting

b. A supportive environment

c. Abuse and neglect

d. Direction and attention

6. The nurse in-charge is displaying assertive behavior when she:

a. Says what’s on her mind at the expense of others

b. Expresses an air of superiority

c. Avoids unpleasant situations and circumstances

d. Stands up for her rights while respecting the rights of others.

7. In a group therapy setting, one male member is very demanding, repeatedly interrupting others and taking most of the group time. The nurse’s best response would be:

a. “Will you briefly summarize your point because others need time also?”

b. “Your behavior is obnoxious and drains the group.”

c. To ignore the behavior and allow him vent

d. “I’m so frustrated with your behavior”

8. The nurse is aware that the primary indication for the use of electroconvulsive therapy (ECT) is:

a. Severe agitation

b. Antisocial behavior

c. Noncompliance with treatment

d. Major depression with psychotic features

9. Two nurses are discussing a female client’s condition in the elevator. The employer of the mentioned client overhears the conversation and fires the client. The nurses may be liable for which act?

a. Assault

b. Battery

c. Neglect

d. Breach of confidentiality

10. A nurse at a substance abuse center answers the phone. A probation officer asks if the male client is in treatment. The nurse responds, “No, the client you’re looking for isn’t here.” Which statement best describes the nurse’s response?

a. Correct because she didn’t give out information about the client

b. A violation of confidentiality because she informed the officer that the client wasn’t there

c. A breach of the principle of veracity because the nurse is misleading the officer

d. Illegal because she’s withholding information from law enforcement agents.

11. The employer of a female client on the psychiatric unit calls the nursing station inquiring about the client’s progress. The nurse doesn’t know if consent has been given by the client to allow the staff to give information out to caller on the phone. Which response by the nurse would be best?

a. “I’m not permitted to discuss her progress.”

b. “I’ll give you the name and telephone number of her physician.”

c. “I’ll have her call you.”

d. “I can’t confirm whether your employee is a client here.”

12. A voluntary male client in a health care facility decided to leave the unit before treatment is complete. To detain the client, the nurse refuses to return his personal effects. This is an example of:

a. False imprisonment

b. Limit setting

c. Slander

d. Violation of confidentiality

13. Which statement is guideline to help nurses avoid liability?

a. Follow every physician’s order

b. Do what the client desires even though you may disagree

c. Practice within the scope of the Nurse Practice Act

d. Obtain malpractice insurance

14. A nurse places a male client in full leather restraints. How often must the nurse check the client’s circulation?

a. Once per hour

b. Once per 8-hour shift

c. Every 15 minutes

d. Every 2 hours

15. Which clinical condition meets the criteria for involuntary commitment?

a. A single parent who leaves her minor children unattended and stays out all night drinking

b. A person who lives alone and has schizophrenia with delusions of persecution

c. A man who threatens to kill his wife

d. A person with depression who says he’s tired of living but doesn’t have a suicide plan

16. An adult client in an acute care mental health program refuses his morning dose of an oral antipsychotic medication and believes he’s being poisoned. The nurse should respond by taking which action?

a. Administering the medication by injection

b. Omitting the dose and trying again the next day

c. Crushing the medication and putting it in his food

d. Consulting with the physician about a care plan

17. A nurse is working with a female dying client and his family. Which communication technique is most important to use?

a. Reflection

b. Interpretation

c. Clarification

d. Active listening

18. A male client receiving morphine for long-term pain management develops tolerance. Tolerance is defined as:

a. An increased response to a medication

b. A diminished response to a drug so that more is required to achieve the same effect

c. An allergic reaction to a medication

d. An ability to take the same drug for extended periods of time.

19. The nurse is aware that the goal of crisis intervention is:

a. To solve the client’s problems for him

b. Psychological resolution of the immediate crisis

c. To establish a means for long-term therapy

d. To provide a means for admission to an acute care facility

20. A male client in a group therapy is restless. His face is flushed and he makes sarcastic remarks to group members. The nurse responds by saying, “You look angry.” The nurse is using which technique?

a. A broad opening statement

b. Reassurance

c. Clarifying

d. Making observations

21. A male patient with antisocial personality disorder smokes where it is prohibited and refuses to follow other unit and hospital rules. The patient gets others to do the laundry and other personal chores, splits the staff, and will work only with certain nurses. The plan of care for this patient should focus primarily on:

a. A consistently enforcing unit rules and hospital policy

b. Isolating the patient to decrease contact with easily manipulated patients

c. Engaging in power struggles with the patient to minimize manipulative behavior

d. Using behavior modification to decrease negative behavior by using negative reinforcement

22. The nurse knows that the doctor in charge has ordered the liquid form of the drug chlorpromazine rather than the tablet form because the liquid?

a. Has a more predictable onset of action

b. Produces fewer anticholinergic effects

c. Produces fewer drug infections

d. Has a longer duration of action

23. A male patient receiving fluphenazine (Prolixen) therapy develops pseudoparkinsonism. The doctor is likely to prescribe which drug to control this extrapyramidal effect?

a. Phenytoin (Dilantin)

b. Amantadine (Symmetrel)

c. Benztropine (Cogentin)

d. Diphenhydramine

24. During a panic attack, a male patient runs to the nurse and reports breathing difficulty, chest pain, and palpitations. The patient is pale, with the mouth wide open and eyebrows raised. What should the nurse do first?

a. Assist the patient to breath deeply into a paper bag

b. Orient the patient to person, place and time

c. Set limits for acting out delusional behaviors

d. Administer an I.M. anxiolytic agent

25. A husband and wife seek emergency crisis intervention because he slapped her repeatedly the night before. The husband says he grew up in a household where his father frequently abused both his mother and him. When interviewing with this couple, the nurse in charge knows they are at risk for repeated violence because the husband:

a. Has only moderate impulse control

b. Denies feelings of jealousy or possessiveness

c. Has learned violence as an acceptable behavior

d. Feels secure in his relationship with his wife

26. What occurs during the working phase of the nurse-patient relationship?

a. The nurse assesses the patient’s needs and develops a plan of care

b. The nurse and patient together evaluate and modify the goals of the relationship

c. The nurse and patient discuss their feelings about terminating the relationship

d. The nurse and patient explore each other’s expectations of the relationship

27. When caring for a male adolescent patient diagnosed with depression, the nurse should remember that depression manifests differently in adolescents and adult. In an adolescent, signs and symptoms of depression are likely to include:

a. Helplessness, hopelessness, hypersomnolence, and anorexia

b. Truancy, a change of friends, social withdrawal, and oppositional behavior

c. Curfew breaking, stealing from family members, truancy, and oppositional behavior

d. Hypersomnolence, obsession with body image, and valuing of peer’s opinion.

28. During the admission assessment, a male patient with a panic disorder begins to hyperventilate and says, “I’m going to die if I don’t get out of here right now!” What is the nurse’s best response?

a. “Just calm down. You’re getting overly anxious.”

b. “What do you think is causing your panic attack?”

c. “You can rest alone in your room until you feel better.”

d. “You’re having panic attack. I’ll stay here with you.”

29. In a female patient with a conversion disorder who reports blindness, ophthalmologic examinations reveal that no organic disorder is causing progressive vision loss. The most likely source of this patient’s blindness is:

a. A family history of major depression

b. Having been forced to watch a loved one’s torture

c. Noncompliance with a psychotropic medication regimen

d. Daily use of antianxiety agents and alcoholic beverages

30. A busy attorney with a successful law practice is admitted to an acute care facility with epigastric pain. Since admission, the patient has called the nurse 15 minutes with one request or another. This patient is exhibiting:

a. Repression

b. Somatization

c. Regression

d. Conversion

Answers and Rationale

Psychiatric Nursing NCLEX Review Part 2 Share this on Facebook Tweet This! Email this via...
Psychiatric Nursing NCLEX Review Part 1 Answers and Rationale Share this on Facebook Tweet This! Email this via...
Psychiatric Nursing NCLEX Review Part 2 Answers and Rationale Share this on Facebook Tweet This! Email this via...

Answers and Rationale Psychiatric Nursing Practice Test I

admin — Tue, 27 Oct 2009 17:16:06 +0000

View Questions

D. An interpreter will enable the nurse to better assess the client’s problems and concerns. Nonverbal communication is important; however for the nurse to fully determine the client’s problems and concerns, the assistance of an interpreter is essential. The use of symbolic pictures and universal phrases may assist the nurse in understanding the basic needs of the client; however these are insufficient to assess the client with a psychiatric problem.
D. Psychoanalytic is based on Freud’s beliefs regarding the importance of unconscious motivation for behavior and the role of the id and superego in opposition to each other. Behavioral cognitive and interpersonal theories do not emphasize unconscious conflicts as the basis for symptomatic behavior.
D. By acknowledging the observed behavior and asking the client to express his feelings the nurse can best assist the client to become aware of his anxiety. In option A, the nurse is offering an interpretation that may or may not be accurate; the nurse is also asking a question that may be answered by a “yes” or “no” response, which is not therapeutic. In option B, the nurse is intervening before accurately assessing the problem. Option C, which also encourages a “yes” or “no” response, avoids focusing on the client’s anxiety, which is the reason for his pacing.
A. A client with obsessive-compulsive behavior uses this behavior to decrease anxiety. Accepting this behavior as the client’s attempt to feel secure is therapeutic. When a specific treatment plan is developed, other nursing responses may also be acceptable. The remaining answer choices will increase the client’s anxiety and therefore are inappropriate.
A. Education and work history would have the least significance in relation to the client’s sexual problem. Age, health status, physical attributes and relationship issues have great influence on sexual expression.
C. Inpatient treatment of a client with anorexia usually focuses initially on establishing a plan for refeeding to combat the effects of self-induced starvation. Refeeding is accomplished through behavioral therapy, which uses a system of rewards and reinforcements to assist in establishing weight restoration. Emphasizing nutrition and teaching the client about the long-term physical consequences of anorexia maybe appropriate at a later time in the treatment program. The nurse needs to assess the client’s mealtime behavior continually to evaluate treatment effectiveness.
A. One of the core issues concerning the family of a client with anorexia is control. The family’s acceptance of the client’s ability to make independent decisions is key to successful family intervention. Although the remaining options may occur during the process of therapy they would not necessarily indicate a successful outcome; the central family issues of dependence and independence are not addressed in these responses.
D. The client with a somatoform disorder displaces anxiety onto physical symptoms. The ability to express anxiety verbally indicates a positive change toward improved health. The remaining responses do not indicate any positive change toward increased coping with anxiety.
C. Directly questioning a client about suicide is important to determine suicide risk. The client may not bring up this subject for several reasons, including guilt regarding suicide, wishing not to be discovered, and his lack of trust in staff. Behavioral cues are important, but direct questioning is essential to determine suicide risk. Indirect questions convey to the client that the nurse is not comfortable with the subject of suicide and, therefore, the client may be reluctant to discuss the topic.
C. A client exhibiting flight of ideas typically has a continuous speech flow and jumps from one topic to another. Speaking in coherent sentences is an indicator that the client’s concentration has improved and his thoughts are no longer racing. The remaining options do not relate directly to the stated nursing diagnosis.
C. The nurse should take any nurse statements indicating suicidal thoughts seriously and further assess for other risk factors. The remaining diagnoses fail to address the seriousness of the client’s statement.
D. This statement provides accurate information and an element of hope for the family of a schizophrenic client. Although the remaining statements are true, they do not provide the empathic response the family needs after just learning about the diagnosis. These facts can become part of the ongoing teaching.
A. A client with schizophrenia, paranoid type, has distorted perceptions and views people, institutions, and aspects of the environment as plotting against him. The desired outcome for someone with delusional perceptions would be to have a realistic interpretation of daily events. The client with a distorted perception of the environment would not necessarily have impairments affecting hygiene and grooming skills. Although taking medications and participating in unit activities may be appropriate outcomes for nursing intervention, these responses are not related to client perceptions.
D. A client with these symptoms would have poor impulse control and would therefore be prone to acting-out behavior that may be harmful to either himself or others. All of the remaining nursing diagnoses may apply to the client with mania; however, the priority diagnosis would be risk for violence.
C. Rationalization is the defense mechanism that involves offering excuses for maladaptive behavior. The client is defending his substance abuse by providing reasons related to life stressors. This is a common defense mechanism used by clients with substance abuse problems. None of the remaining defense mechanisms involves making excuses for behaviors.
B. Physical aggressiveness, low stress tolerance, and a disregard for the rights of others are common behaviors in clients with conduct disorders. Restlessness, short attention span, and hyperactivity are typical behaviors in a client with attention deficit hyperactivity disorder. Deterioration in social functioning, excessive anxiety and worry and bizarre behaviors are typical in schizophrenic disorders. Sadness, poor appetite, sleeplessness, and loss of interest in activities are behaviors commonly seen in depressive disorders.
B. Babies born to heroin-dependent women are also heroin-dependent and need to go through withdrawal. There is no evidence to support any of the remaining answer choices.
D. Establishing an unbroken chain of evidence is essential in order to ensure that the prosecution of the perpetrator can occur. The nurse will also need to preserve the client’s privacy and identify the extent of injury. However, it is essential that the nurse follow legal and agency guidelines for preserving evidence. Identifying the assailant is the job of law enforcement, not the nurse.
D. Socioeconomic status is not a reliable predictor of abuse in the home, so it would be the least important consideration in deciding issues of safety for the victim of family violence. The availability of appropriate community shelters and the ability of the nonabusing caretaker to intervene on the client’s behalf are important factors when making safety decisions. The client’s response to possible relocation (if the client is a competent adult) would be the most important factor to consider; feelings of empowerment and being treated as a competent person can help a client feel less like a victim.
A. In the early stage of Alzheimer’s disease, complex tasks (such as balancing a checkbook) would be the first cognitive deficit to occur. The loss of self-care ability, problems with relating to family members, and difficulty remembering one’s own name are all areas of cognitive decline that occur later in the disease process.
C. The client with Alzheimer’s disease can have frequent episode of labile mood, which can best be handled by decreasing a stimulating environment and redirecting the client’s attention. An over stimulating environment may cause the labile mood, which will be difficult for the client to understand. The client with Alzheimer’s disease loses the cognitive ability to respond to either humor or logic. The client lacks any insight into his or her own behavior and therefore will be unaware of any causative factors.
A. A relative deficiency of acetylcholine is associated with this disorder. The drugs used in the early stages of Alzheimer’s disease will act to increase available acetylcholine in the brain. The remaining neurotransmitters have not been implicated in Alzheimer’s disease.
C. The most important factors to determine in this situations are the client’s perception of the crisis event and the availability of support (including family and friends) to provide basic needs. Although the nurse should assess the other factors, they are not as essential as determining why the client considers this a crisis and whether he can meet his present needs.
D. Crisis intervention is based on the idea that a crisis is a disturbance in homeostasis (steady state). The goal is to help the client return to a previous level of equilibrium in functioning. The remaining answer choices are not considered the primary outcome of crisis intervention, although they may occur as a side benefit.
B. Increased anxiety and uncertainly characterize the initiation phase in group therapy. Group members are more self-reliant during the working and termination phases.
A. As the group progresses into the working phase, group members assume more responsibility for the group. The leader becomes more of a facilitator. Comments about behavior in a group are indicators that the group is active and involved. The remaining answer choices would indicate the group progress has not advanced to the working phase.
C. The use of diuretics would cause sodium and water excretion, which would increase the risk of lithium toxicity. Clients taking lithium carbonate should be taught to increase their fluid intake and to maintain normal intake of sodium. Concurrent use of any of the remaining medications will not increase the risk of lithium toxicity.
D. In a functional family, parents typically do not agree on all issues and problems. Open discussion of thoughts and feeling is healthy, and parental disagreement should not cause system stress. The remaining answer choices are life transitions that are expected to increase family stress.
A. Aged cheese and red wines contain the substance tyramine which, when taken with an MAOI, can precipitate a hypertensive crisis. The other foods and beverages do not contain significant amounts of tyramine and, therefore, are not restricted.
C. Because chlorpromazine (Thorazine) can cause a significant hypotensive effect (and possible client injury), the nurse must assess the client’s blood pressure (lying, sitting, and standing) before administering this drug. If the client had taken the drug previously, the nurse would also need to assess the skin color and sclera for signs of jaundice, a possible drug side affect; however, based on the information given here, there is no evidence that the client has received chlorpromazine before. Although the drug can cause urine retention, asking the client to avoid will not alter this anticholinergic effect.
B. The onset of action of the SSRI antidepressant paroxetine occurs around 3 to 4 weeks after drug therapy begins. Therefore, a client will seldom notice improvement before this time. Continuing to take the drug is important for this client.
B. Over-the-counter medications used for allergies and cold symptoms are contraindicated because they will increase the sympathomimetic effects of MAOIs, possibly causing a hypertensive crisis. None of the remaining medications will increase the sympathomimetic response and, therefore, are not contraindicated.
C. Urinary retention is a common anticholinergic side effect of psychotic medications, and the client with benign prostatic hypertrophy would have increased risk for this problem. Adding fiber to one’s diet and exercising regularly are measures to counteract another anticholinergic effect, constipation. Depending on the specific medication and how it is prescribed, taking the medication at night may or may not be important. However, it would have nothing to do with urinary retention in this client.
B. Coffee contains caffeine, which has a stimulating effect on the central nervous system that will counteract the effect of the antianxiety medication oxazepam. None of the remaining foods is contraindicated.
B. The primary purpose of Alcoholics Anonymous is to help members achieve and maintain sobriety. Although each of the remaining answer choices may be an outcome of attendance at Alcoholics Anonymous, the primary purpose is directed toward sobriety of members.
C. A therapeutic community is designed to help individuals assume responsibility for themselves, to learn how to respect and communicate with others, and to interact in a positive manner. The remaining answer choices may be outcomes of psychiatric treatment, but the use of a therapeutic community approach is concerned with promotion of self-reliance and cooperative adaptation to being with others.
ADCBE. The nurse should remain with the client to provide support and promote safety. Reducing external stimuli, including dimming lights and avoiding crowded areas, will help decrease anxiety. Encouraging the client to use slow, deep breathing will help promote the body’s relaxation response, thereby interrupting stimulation from the autonomic nervous system. Encouraging physical activity will help him to release energy resulting from the heightened anxiety state; this should be done only after the client has brought his breathing under control. Teaching coping measures will help the client learn to handle anxiety; however, this can only be accomplished when the client’s panic has dissipated and he is better able to focus.
C. Set up the problem as follows: 2.5mg/10mg = Xml/2ml X=0.5ml
C. The initial, most basic assessment of a client with cognitive impairment involves determining his level of orientation (awareness of time, place, and person). The nurse may also assess for confabulation and perseveration in a client with cognitive impairment; but the questions in this situation would not elicit the symptom response. Delirium is a type of cognitive impairment; however, other symptoms are necessary to establish this diagnosis.
D. Short words and simple sentence minimize client confusion and enhance communication. Complete explanations with multiple details and stimulating words and phrases would increase confusion in a client with short attention span and difficulty with comprehension. Although pictures and gestures may be helpful, they would not substitute for verbal communication.
D. Confabulation is a communication device used by patients with dementia to compensate for memory gaps. The remaining answer choices are incorrect.
C. Maintaining a calm approach when intervening with an agitated client is extremely important. Telling the client firmly that it is time to get dressed may increase his agitation, especially if the nurse touches him. Restraints are a last resort to ensure client safety and are inappropriate in this situation. Sedation should be avoided, if possible, because it will interfere with CNS functioning and may contribute to the client’s confusion.
C. Sundowning is a common phenomenon that occurs after daylight hours in a client with a cognitive impairment disorder. The other options are incorrect responses, although all may be seen in this client.
D. Following established activity schedules is a realistic expectation for clients with dementia. All of the remaining outcome statements require a higher level of cognitive ability than can be realistically expected of clients with this disorder.
C. The family’s perception of the problem is essential because change in any one part of a family system affects all other parts and the system as a whole. Each member of the family has been affected by the current problems related to the school system and the nurse would be interested in the data. The child’s performance in school and the teacher’s attempts to solve the problem are relevant and may be assessed; however, priority would be given to the family’s perception of the problem. The family education and work history may be relevant, but are not a priority.
B. Te parents are feeling responsible and this inappropriate self-blame can be limited by supplying them with the facts about the biologic basis of schizophrenia. Acknowledging the patient’s responsibility is neither accurate nor helpful to the parents and would only reinforce their feelings of guilt. Support groups are useful; however, the nurse needs to handle the parents’ self-blame directly instead of making a referral for this problem. Teaching the parents various ways to change would reinforce the parental assumption of blame; although parents can learn about schizophrenia and what is helpful and not helpful, the approach suggested in this option implies the parents’ behavior is at fault.
A. Family boundaries are parameters that define who is inside and outside the system. The best method of obtaining this information is asking the family directly who they consider to be members. The question asked by the nurse would not elicit information about the family’s ethnicity or culture, nor does it address the nature of the family relationship.
B. Differentiation is the process of becoming an individual developing autonomy while staying in contact with the family system. Cooperative action among family members does not refer to differentiation, although individuals who have a high level of differentiation would be able to accomplish cooperative action. Incongruent messages in which the recipient is a victim describe double-bind communication. Maintenance of system continuity or equilibrium is homeostasis.
D. The nurse who wishes to be helpful to the entire family must remain neutral. Taking sides in a conflict situation in a family will not encourage negotiation, which is important for problem resolution. If the nurse aligned with the adolescent, then the nurse would be blaming the parents for the child’s current problem; this would not help the family’s situation. Learning to negotiate conflict is a function of a healthy family. Encouraging the parents to adopt more realistic rules or the adolescent to comply with parental rules does not give the family an opportunity to try to resolve problems on their own.
C. Enmeshment is a fusion or overinvolvement among family members whereby the expectation exists that all members think and act alike. The child who always acts to please her parents is an example of how enmeshment affects development in many cases, a child who develops anorexia nervosa exerts control only in the area of eating behavior. The remaining options are not appropriate to the situation described.

Psychiatric Nursing Practice Test I Share this on Facebook Tweet This! Email this via...
Answers and Rationale of NCLEX Sample Questions for Psychiatric Nursing 2 Share this on Facebook Tweet This! Email this via...
Psychiatric Nursing NCLEX Review Part 2 Answers and Rationale Share this on Facebook Tweet This! Email this via...

Psychiatric Nursing Practice Test I

admin — Sun, 25 Oct 2009 22:16:11 +0000

1. Which nursing intervention is best for facilitating communication with a psychiatric client who speaks a foreign language?

a. Rely on nonverbal communication.

b. Select symbolic pictures as aids.

c. Speak in universal phrases.

d. Use the services of an interpreter.

2. The nurse explains to a mental health care technician that a client’s obsessive-compulsive behaviors are related to unconscious conflict between id impulses and the superego (or conscience). On which of the following theories does the nurse base this statement?

a. Behavioral theory

b. Cognitive theory

c. Interpersonal theory

d. Psychoanalytic theory

3. The nurse observes a client pacing in the hall. Which statement by the nurse may help the client recognize his anxiety?

a. “I guess you’re worried about something, aren’t you?

b. “Can I get you some medication to help calm you?”

c. “Have you been pacing for a long time?”

d. “I notice that you’re pacing. How are you feeling?”

4. A client with obsessive-compulsive disorder is hospitalized on an inpatient unit. Which nursing response is most therapeutic?

a. Accepting the client’s obsessive-compulsive behaviors

b. Challenging the client’s obsessive-compulsive behaviors

c. Preventing the client’s obsessive-compulsive behaviors

d. Rejecting the client’s obsessive-compulsive behaviors

5. A 45-year-old woman with a history of depression tells a nurse in her doctor’s office that she has difficulty with sexual arousal and is fearful that her husband will have an affair. Which of the following factors would the nurse identify as least significant in contributing to the client’s sexual difficulty?

a. Education and work history

b. Medication used

c. Physical health status

d. Quality of spousal relationship

6. Which nursing intervention is most appropriate for a client with anorexia nervosa during initial hospitalization on a behavioral therapy unit?

a. Emphasize the importance of good nutrition to establish normal weight.

b. Ignore the client’s mealtime behavior and focus instead on issues of dependence and independence.

c. Help establish a plan using privileges and restrictions based on compliance with refeeding.

d. Teach the client information about the long-term physical consequence of anorexia.

7. A nurse is evaluating therapy with the family of a client with anorexia nervosa. Which of the following would indicate that the therapy was successful?

a. The parents reinforce increased decision making by the client.

b. The parents clearly verbalize their expectations for the client.

c. The client verbalizes that family meals are now enjoyable.

d. The client tells her parents about feelings of low-self-esteem.

8. The nurse is working with a client with a somatoform disorder. Which client outcome goal would the nurse most likely establish in this situation?

a. The client will recognize signs and symptoms of physical illness.

b. The client will cope with physical illness.

c. The client will take prescribed medications.

d. The client will express anxiety verbally rather than through physical symptoms.

9. Which method would a nurse use to determine a client’s potential risk for suicide?

a. Wait for the client to bring up the subject of suicide.

b. Observe the client’s behavior for cues of suicide ideation.

c. Question the client directly about suicidal thoughts.

d. Question the client about future plans.

10. A client with a bipolar disorder exhibits manic behavior. The nursing diagnosis is Disturbed thought processes related to difficulty concentrating, secondary to flight of ideas. Which of the following outcome criteria would indicate improvement in the client?

a. The client verbalizes feelings directly during treatment.

b. The client verbalizes positive “self” statement.

c. The client speaks in coherent sentences.

d. The client reports feelings calmer.

11. A client tells a nurse. “Everyone would be better off if I wasn’t alive.” Which nursing diagnosis would be made based on this statement?

a. Disturbed thought processes

b. Ineffective coping

c. Risk for self-directed violence

d. Impaired social interaction

12. Which information is most essential in the initial teaching session for the family of a young adult recently diagnosed with schizophrenia?

a. Symptoms of this disease imbalance in the brain.

b. Genetic history is an important factor related to the development of schizophrenia.

c. Schizophrenia is a serious disease affecting every aspect of a person’s functioning.

d. The distressing symptoms of this disorder can respond to treatment with medications.

13. A nurse is working with a client who has schizophrenia, paranoid type. Which of the following outcomes related to the client’s delusional perceptions would the nurse establish?

a. The client will demonstrate realistic interpretation of daily events in the unit.

b. The client will perform daily hygiene and grooming without assistance.

c. The client will take prescribed medications without difficulty.

d. The client will participate in unit activities.

14. A client with bipolar disorder, manic type, exhibits extreme excitement, delusional thinking, and command hallucinations. Which of the following is the priority nursing diagnosis?

a. Anxiety

b. Impaired social interaction

c. Disturbed sensory-perceptual alteration (auditory)

d. Risk for other-directed violence

15. A client who abuses alcohol and cocaine tells a nurse that he only uses substances because of his stressful marriage and difficult job. Which defense mechanisms is this client using?

a. Displacement

b. Projection

c. Rationalization

d. Sublimation

16. An 11-year-old child diagnosed with conduct disorder is admitted to the psychiatric unit for treatment. Which of the following behaviors would the nurse assess?

a. Restlessness, short attention span, hyperactivity

b. Physical aggressiveness, low stress tolerance disregard for the rights of others

c. Deterioration in social functioning, excessive anxiety and worry, bizarre behavior

d. Sadness, poor appetite and sleeplessness, loss of interest in activities

17. The nurse understands that if a client continues to be dependent on heroin throughout her pregnancy, her baby will be at high risk for:

a. Mental retardation.

b. Heroin dependence.

c. Addiction in adulthood.

d. Psychological disturbances.

18. The emergency department nurse is assigned to provide care for a victim of a sexual assault. When following legal and agency guidelines, which intervention is most important?

a. Determine the assailant’s identity.

b. Preserve the client’s privacy.

c. Identify the extent of injury.

d. Ensure an unbroken chain of evidence.

19. Which factor is least important in the decision regarding whether a victim of family violence can safely remain in the home?

a. The availability of appropriate community shelters

b. The nonabusing caretaker’s ability to intervene on the client’s behalf

c. The client’s possible response to relocation

d. The family’s socioeconomic status

20. The nurse would expect a client with early Alzheimer’s disease to have problems with:

a. Balancing a checkbook.

b. Self-care measures.

c. Relating to family members.

d. Remembering his own name

21. Which nursing intervention is most appropriate for a client with Alzheimer’s disease who has frequent episodes emotional lability?

a. Attempt humor to alter the client mood.

b. Explore reasons for the client’s altered mood.

c. Reduce environmental stimuli to redirect the client’s attention.

d. Use logic to point out reality aspects.

22. Which neurotransmitter has been implicated in the development of Alzheimer’s disease?

a. Acetylcholine

b. Dopamine

c. Epinephrine

d. Serotonin

23. Which factors are most essential for the nurse to assess when providing crisis intervention foe a client?

a. The client’s communication and coping skills

b. The client’s anxiety level and ability to express feelings

c. The client’s perception of the triggering event and availability of situational supports

d. The client’s use of reality testing and level of depression

24. The nurse considers a client’s response to crisis intervention successful if the client:

a. Changes coping skills and behavioral patterns.

b. Develops insight into reasons why the crisis occurred.

c. Learns to relate better to others.

d. Returns to his previous level of functioning.

25. Two nurses are co-leading group therapy for seven clients in the psychiatric unit. The leaders observe that the group members are anxious and look to the leaders for answers. Which phase of development is this group in?

a. Conflict resolution phase

b. Initiation phase

c. Working phase

d. Termination phase

26. Group members have worked very hard, and the nurse reminds them that termination is approaching. Termination is considered successful if group members:

a. Decide to continue.

b. Elevate group progress

c. Focus on positive experience

d. Stop attending prior to termination.

27. The nurse is teaching a group of clients about the mood-stabilizing medications lithium carbonate. Which medications should she instruct the clients to avoid because of the increased risk of lithium toxicity?

a. Antacids

b. Antibiotics

c. Diuretics

d. Hypoglycemic agents

28. When providing family therapy, the nurse analyzes the functioning of healthy family systems. Which situations would not increase stress on a healthy family system?

a. An adolescent’s going away to college

b. The birth of a child

c. The death of a grandparent

d. Parental disagreement

29. A client taking the monoamine oxidase inhibitor (MAOI) antidepressant isocarboxazid (Marplan) is instructed by the nurse to avoid which foods and beverages?

a. Aged cheese and red wine

b. Milk and green, leaf vegetables

c. Carbonated beverages and tomato products

d. Lean red meats and fruit juices

30. Prior to administering chlorpromazine (Thorazine) to an agitated client, the nurse should:

a. Assess skin color and sclera

b. Assess the radial pulse

c. Take the client’s blood pressure

d. Ask the client to void

31. The nurse understands that electroconvulsive therapy is primary used in psychiatric care for the treatment of:

a. Anxiety disorders.

b. Depression.

c. Mania.

d. Schizophrenia.

32. A client taking the MAOI phenelzine (Nardil) tells the nurse that he routinely takes all of the medications listed below. Which medication would cause the nurse to express concern and therefore initiate further teaching?

a. Acetaminophen (Tylenol)

b. Diphenhydramine (Benadryl)

c. Furosemide (Lasix)

d. Isosorbide dinitrate (Isordil)

33. The nurse is administering a psychotropic drug to an elderly client who has history of benign prostatic hypertrophy. It is most important for the nurse to teach this client to:

a. Add fiber to his diet.

b. Exercise on a regular basis.

c. Report incomplete bladder emptying

d. Take the prescribed dose at bedtime.

34. The nurse correctly teaches a client taking the benzodiazepine oxazepam (Serax) to avoid excessive intake of:

a. Cheese

b. Coffee

c. Sugar

d. Shellfish

35. The nurse provides a referral to Alcoholics Anonymous to a client who describes a 20-year history of alcohol abuse. The primary function of this group is to:

a. Encourage the use of a 12-step program.

b. Help members maintain sobriety.

c. Provide fellowship among members.

d. Teach positive coping mechanisms.

36. Which client outcome is most appropriately achieved in a community approach setting in psychiatric nursing?

a. The client performs activities of daily living and learns about crafts.

b. The client’s is able to prevent aggressive behavior and monitors his use of medications.

c. The client demonstrates self-reliance and social adaptation.

d. The client experience experiences anxiety relief and learns about his symptoms.

37. A client with panic disorder experiences an acute attack while the nurse is completing an admission assessment. List the following interventions according to their level of priority.

a. Remain with the client.

b. Encourage physical activity.

c. Encourage low, deep breathing.

d. Reduce external stimuli.

e. Teach coping measures.

38. The doctor has prescribed haloperidol (Haldol) 2.5 mg. I.M. for an agitated client. The medication is labeled haloperidol 10 mg/2 ml. The nurse prepares the correct dose by drawing up how many milliliters in the syringe?

a. 0.3

b. 0.4

c. 0.5

d. 0.6

39. The nurse enters the room of a client with a cognitive impairment disorder and asks what day of the week it is: what the date, month, and year are; and where the client is. The nurse is attempting to assess:

a. Confabulation

b. Delirium

c. Orientation

d. Perseveration

40. Which of the following will the nurse use when communicating with a client who has a cognitive impairment?

a. Complete explanations with multiple details

b. Picture or gestures instead of words

c. Stimulating words and phrases to capture the client’s attention

d. Short words and simple sentences

41. A 75-year-old client has dementia of the Alzheimer’s type and confabulates. The nurse understands that this client:

a. Denies confusion by being jovial.

b. Pretends to be someone else.

c. Rationalizes various behaviors.

d. Fills in memory gaps with fantasy.

42. An elderly client with Alzheimer’s disease becomes agitated and combative when a nurse approaches to help with morning care. The most appropriate nursing intervention in this situation would be to:

a. Tell the client family that it is time to get dressed.

b. Obtain assistance to restrain the client for safety.

c. Remain calm and talk quietly to the client.

d. Call the doctor and request an order for sedation.

43. In clients with a cognitive impairment disorder, the phenomenon of increased confusion in the early evening hours is called:

a. Aphasia

b. Agnosia

c. Sundowning

d. Confabulation

44. Which of the following outcome criteria is appropriate for the client with dementia?

a. The client will return to an adequate level of self-functioning.

b. The client will learn new coping mechanisms to handle anxiety.

c. The client will seek out resources in the community for support.

d. The client will follow an establishing schedule for activities of daily living.

45. The school guidance counselor refers a family with an 8-year-old child to the mental health clinic because of the child’s frequent fighting in school and truancy. Which of the following data would be a priority to the nurse doing the initial family assessment?

a. The child’s performance in school

b. Family education and work history

c. The family’s perception of the current problem

d. The teacher’s attempts to solve the problem

46. The parents of a young man with schizophrenia express feelings of responsibility and guilt for their son’s problems. How can the nurse best educate the family?

a. Acknowledge the parent’s responsibility.

b. Explain the biological nature of schizophrenia.

c. Refer the family to a support group

d. Teach the parents various ways they must change.

47. The nurse collecting family assessment data asks. “Who is in your family and where do they live?” which of the following is the nurse attempting o identify?

a. Boundaries

b. Ethnicity

c. Relationships

d. Triangles

48. According to the family systems theory, which of the following best describes the process of differentiation?

a. Cooperative action among members of the family

b. Development of autonomy within the family

c. Incongruent massages wherein the recipient is a victim

d. Maintenance of system continuity or equilibrium

49. The nurse is interacting with a family consisting of a mother, a father, and a hospitalized adolescent who has a diagnosis of alcohol abuse. The nurse analyzes the situation and agrees with the adolescent’s view about family rules. Which intervention is most appropriate?

a. The nurse should align with the adolescent, who is the family scapegoat.

b. The nurse should encourage the parents to adopt more realistic rules.

c. The nurse should encourage the adolescent to comply with parental rules.

d. The nurse should remain objective and encourage mutual negotiation of issues.

50. A 16-year-old girl has retuned home following hospitalization for treatment of anorexia nervosa. The parents tell the family nurse performing a home visit that their child has always done everything to please them and they cannot understand her current stubbornness about eating. The nurse analyzes the family situation and determines it is characteristic of which relationship style?

a. Differentiation

b. Disengagement

c. Enmeshment

d. Scapegoating

View Answers and Rationale

Answers and Rationale Psychiatric Nursing Practice Test I Share this on Facebook Tweet This! Email this via...
Psychiatric Nursing NCLEX Review Part 2 Answers and Rationale Share this on Facebook Tweet This! Email this via...
Psychiatric Nursing NCLEX Review Part 2 Share this on Facebook Tweet This! Email this via...