1. A man is admitted to the nursing care unit with a diagnosis of cirrhosis. He has a long history of alcohol dependence. During the late evening following his admission, he becomes increasingly disoriented and agitated. Which of the following would the client be least likely to experience? a. Diaphoresis and tremors. b. Increased blood pressure and heart rate. c. Illusions. d. Delusions of grandeur.
2. Mr. Wilson, 35, is admitted for bipolar illness, manic phase, after assaulting his landlord in an argument over Mr. Wilson’s staying up all night playing loud music. Mr. Wilson’s is hyperactive, intrusive, and has rapid, pressured speech. He has not slept in three days and appears thin and disheveled. Which of the following is the most essential nursing action at this time? a. Providing a meal and beverage for Mr. Wilson to eat in the dining room. b. Providing linens and toiletries for Mr. Wilson to attend to his hygiene. c. Consulting with the psychiatrist to order a hypnotic to promote sleep. d. Providing for client safety by limiting his privileges.
3. Which of the following would best indicate to the nurse that a depressed client is improving? a. Reduced levels of anxiety. b. Changes in vegetative signs. c. Compliance with medications. d. Requests to talk to the nurse.
4. An elderly man is admitted to the hospital. He was alert and oriented during the admission interview. However, his family states that he becomes disruptive and disoriented around dinnertime. One night he was shouting furiously and didn’t know where he was. He was sedated and the next morning he was fine. At dinnertime the disruptive behavior returned. The client is diagnosed as having sundown syndrome. The client’s son asks the nurse what causes sundown syndrome. The nurse’s best response is that it is attributed to a. an underlying depression. b. inadequate cerebral flow. c. changes in the sensory environment. d. fluctuating levels of oxygen exchange.
5. The nurse is discussing electroconvulsive therapy (ECT) with a client who asks how long it will be before she feels better. The nurse explains that the beneficial effects of ECT usually occur within a. one week. b. three weeks. c. four weeks. d. six weeks.
6. The nurse is assessing a 17-year-old female who is admitted to the eating disorders unit with a history of weight fluctuation, abdominal pain, teeth erosion, receding gums, and bad breath. She states that her health has been a problem but there are no other concerns in her life. Which of the following assessments will be the least useful as the nurse develops the care plan? a. Information regarding recent mood changes. b. Family functioning using a genogram. c. Ability to socialize with peers. d. Whether she has a sexual relationship with a boyfriend.
7. A 34-year-old woman is admitted for treatment of depression. Which of these symptoms would the nurse be least likely to find in the initial assessment? a. inability to make decisions. b. feelings of hopelessness. c. family history of depression. d. increased interest in sex.
8. The nurse is planning care for a client who has a phobic disorder manifested by a fear of elevators. Which goal would need to be accomplished first? The client a. demonstrates the relaxation response when asked. b. verbalizes the underlying cause of the disorder. c. rides the elevator in the company of the nurse. d. role plays the use of an elevator.
9. A teenage female is admitted with the diagnosis of anorexia nervosa. Upon admission, the nurse finds a bottle of assorted pills in the client’s drawer. The client tells the nurse that they are antacids for stomach pains. The best response by the nurse would be a. "These pills aren’t antacids since they are all different." b. "Some teenagers use pills to lose weight." c. "Tell me about your week prior to being admitted." d. "Are you taking pills to change your weight?"
10. A mother with a Roman Catholic belief has given birth in an ambulance on the way to the hospital. The neonate is in very critical condition with little expectation of surviving the trip to the hospital. Which of these requests should the nurse in the ambulance anticipate and be prepared to do? a. The refusal of any treatment for self and the neonate until she talks to a reader b. The placement of a rosary necklace around the neonate’s neck and not to remove it unless absolutely necessary c. Arrange for a church elder to be at the emergency department when the ambulance arrives so a "laying on hands" can be done d. Pour fluid over the forehead backwards towards the back of the head and say "I baptize you in the name of the father, the son and the holy spirit. Amen."
11. Which statement by the client during the initial assessment in the the emergency department is most indicative for suspected domestic violence? a. "I am determined to leave my house in a week." b. "No one else in the family has been treated like this." c. "I have only been married for 2 months." d. "I have tried leaving, but have always gone back."
12. Which of these statements by the nurse reflects the best use of therapeutic interaction techniques? a. "You look upset. Would you like to talk about it?" b. "I’d like to know more about your family. Tell me about them." c. "I understand that you lost your partner. I don’t think I could go on if that happened to me." d. "You look very sad. How long have you been this way?"
13. When planning the therapeutic milieu, it is MOST important to select group activities which a. Match the clients’ preferences b. Are consistent with clients’ skills c. Achieve clients’ therapeutic goals d. Build skills of group participation
14. A client was admitted to the psychiatric unit for severe depression. After several days, the client continues to withdraw from other clients. Which of the following would be the MOST appropriate statement by the nurse to promote interaction with other clients? a. "Your doctor thinks its good for you to spend time with others." b. "It is important for you to participate in group activities." c. "Painting this picture will help you feel better." d. "Come play Chinese Checkers with Gerry and me."
15. The nurse can BEST ensure the safety of a demented client who wanders from the room by a. Repeatedly reminding the client of time and place b. Explaining the risks of becoming lost c. Using soft restraints d. Attaching a wander-guard sensor band to the client’s wrist
16. A client with paranoid thoughts refuses to eat because he believes the food is poisoned. The MOST appropriate initial action is to a. Taste the food in the client’s presence b. Suggest that food be brought from home c. Simply state the food is not poisoned d. Inform the client he will be tube fed if he does not eat
17. The nurse is caring for a severely depressed client who has just been admitted to the in-client psychiatric unit. Which of the following is a PRIORITY of care? a. Nutrition b. Elimination c. Rest d. Safety
18. A nurse is teaching a stress-management program for client. Which of the following beliefs will the nurse advocate as a method of coping with stressful life events? a. Avoidance of stress is an important goal for living. b. Control over one’s response to stress is possible. c. Most people have no control over their level of stress. d. Significant others are important to provide care and concern.
19. A student nurse is caring for a 75-year-old client who is very confused. The student’s communication tools should include: a. written directions for bathing. b. speaking very loudly. c. gentle touch while guiding ADLs (activities of daily living). d. flat facial expression.
20. When a husband takes out his work frustrations and anger by abusing his wife at home, the nurse would identify this crisis as which type? a. psychiatric emergency crisis b. developmental crisis c. anticipated life transition d. dispositional crisis