1.Situation : The nurse assigned in the detoxification unit attends to various patients with substance-related disorders. A 45 years old male revealed that he experienced a marked increase in his intake of alcohol to achieve the desired effect This indicates:
2.The client admitted for alcohol detoxification develops increased tremors, irritability, hypertension and fever. The nurse should be alert for impending:
3.The care for the client places priority to which of the following:
a.Monitoring his vital signs every hour
b.Providing a quiet, dim room
c.Encouraging adequate fluids and nutritious foods
d.Administering Librium as ordered
4.Another client is brought to the emergency room by friends who state that he took something an hour ago. He is actively hallucinating, agitated, with irritated nasal septum.
5.A client is admitted with needle tracts on his arm, stuporous and with pin point pupil will likely be managed with:
6.Situation: An old woman was brought for evaluation due to the hospital for evaluation due to increasing forgetfulness and limitations in daily function. The daughter revealed that the client used her toothbrush to comb her hair. She is manifesting:
7.She tearfully tells the nurse “I can’t take it when she accuses me of stealing her things.” Which response by the nurse will be most therapeutic?
a.”Don’t take it personally. Your mother does not mean it.”
b.“Have you tried discussing this with your mother?”
c.“This must be difficult for you and your mother.”
d.“Next time ask your mother where her things were last seen.”
8.The primary nursing intervention in working with a client with moderate stage dementia is ensuring that the client:
a.receives adequate nutrition and hydration
b.will reminisce to decrease isolation
c.remains in a safe and secure environment
d.independently performs self care
9.She says to the nurse who offers her breakfast, “Oh no, I will wait for my husband. We will eat together” The therapeutic response by the nurse is:
a.“Your husband is dead. Let me serve you your breakfast.”
b.“I’ve told you several times that he is dead. It’s time to eat.”
c.“You’re going to have to wait a long time.”
d.“What made you say that your husband is alive?
10.Dementia unlike delirium is characterized by:
c.clouding of consciousness
d.sensory perceptual change
11.Situation: A 17 year old gymnast is admitted to the hospital due to weight loss and dehydration secondary to starvation. Which of the following nursing diagnoses will be given priority for the client?
b.fluid volume deficit
c.altered nutrition less than body requirements
d.altered family process
12.What is the best intervention to teach the client when she feels the need to starve?
a.Allow her to starve to relieve her anxiety
b.Do a short term exercise until the urge passes
c.Approach the nurse and talk out her feelings
d.Call her mother on the phone and tell her how she feels
13.The client with anorexia nervosa is improving if:
a.She eats meals in the dining room.
c.She attends ward activities.
d.She has a more realistic self concept.
14.The characteristic manifestation that will differentiate bulimia nervosa from anorexia nervosa is that bulimic individuals
a.have episodic binge eating and purging
b.have repeated attempts to stabilize their weight
c.have peculiar food handling patterns
d.have threatened self-esteem
15.A nursing diagnosis for bulimia nervosa is powerlessness related to feeling not in control of eating habits. The goal for this problem is:
a.Patient will learn problem solving skills
b.Patient will have decreased symptoms of anxiety.
c.Patient will perform self care activities daily.
d.Patient will verbalize how to set limits on others.
16.In the management of bulimic patients, the following nursing interventions will promote a therapeutic relationship EXCEPT:
a.Establish an atmosphere of trust
b.Discuss their eating behavior.
c.Help patients identify feelings associated with binge-purge behavior
d.Teach patient about bulimia nervosa
17.Situation: A 35 year old male has intense fear of riding an elevator. He claims “ As if I will die inside.” This has affected his studies The client is suffering from:
18.Initial intervention for the client should be to:
a.Encourage to verbalize his fears as much as he wants.
b.Assist him to find meaning to his feelings in relation to his past.
c.Establish trust through a consistent approach.
d.Accept her fears without criticizing.
19.The nurse develops a countertransference reaction. This is evidenced by:
a.Revealing personal information to the client
b.Focusing on the feelings of the client.
c.Confronting the client about discrepancies in verbal or non-verbal behavior
d.The client feels angry towards the nurse who resembles his mother.
20.Which is the desired outcome in conducting desensitization:
a.The client verbalize his fears about the situation
b.The client will voluntarily attend group therapy in the social hall.
c.The client will socialize with others willingly
d.The client will be able to overcome his disabling fear.
21.Which of the following should be included in the health teachings among clients receiving Valium:
a.Avoid taking CNS depressant like alcohol.
b.There are no restrictions in activities.
c.Limit fluid intake.
d.Any beverage like coffee may be taken
22.Situation: A 20 year old college student is admitted to the medical ward because of sudden onset of paralysis of both legs. Extensive examination revealed no physical basis for the complaint. The nurse plans intervention based on which correct statement about conversion disorder?
a.The symptoms are conscious effort to control anxiety
b.The client will experience high level of anxiety in response to the paralysis.
c.The conversion symptom has symbolic meaning to the client
d.A confrontational approach will be beneficial for the client.
23.Nina reveals that the boyfriend has been pressuring her to engage in premarital sex. The most therapeutic response by the nurse is:
a.“I can refer you to a spiritual counselor if you like.”
b.“You shouldn’t allow anyone to pressure you into sex.”
c.“It sounds like this problem is related to your paralysis.”
d.“How do you feel about being pressured into sex by your boyfriend?”
24.Malingering is different from somatoform disorder because the former:
a.Has evidence of an organic basis.
b.It is a deliberate effort to handle upsetting events
c.Gratification from the environment are obtained.
d.Stress is expressed through physical symptoms.
25.Unlike psychophysiologic disorder Linda may be best managed with: