You have completed November 2009 Pre-Board Exam

TEST IVAll the questions in the quiz along with their answers are shown below. Your answers are bolded. The correct answers have a green background while the incorrect ones have a red background.1. Following spinal injury, the nurse should encourage the client to drink fluids to avoid: A) Urinary tract infection. B) Fluid and electrolyte imbalance. C) Dehydration. D) Skin breakdown.Clients in the early stage of spinal cord damage experience an atonic bladder, which is characterized by the absence of muscle tone, an enlarged capacity, no feeling of discomfort with distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid intake limits urinary stasis and infection by diluting the urine and increasing urinary output.2. The client is transferred from the operating room to recovery room after an open-heart surgery. The nurse assigned is taking the vital signs of the client. The nurse notified the physician when the temperature of the client rises to 38.8 C or 102 F because elevated temperatures: A) May be a forerunner of hemorrhage. B) Are related to diaphoresis and possible chilling. C) May indicate cerebral edema. D) Increase the cardiac output.The temperature of 102 F (38.8C) or greater lead to an increased metabolism and cardiac workload.3. After radiation therapy for cancer of the prostate, the client experienced irritation in the bladder. Which of the following sign of bladder irritability is correct? A) Hematuria B) Dysuria C) Polyuria D) DribblingDysuria, nocturia, and urgency are all signs an irritable bladder after radiation therapy.4. A client is diagnosed with a brain tumor in the occipital lobe. Which of the following will the client most likely experience? A) Visual hallucinations. B) Receptive aphasia. C) Hemiparesis. D) Personality changes.The occipital lobe is involve with visual interpretation.5. A client with Addisons disease has a blood pressure of 65/60. The nurse understands that decreased blood pressure of the client with Addisons disease involves a disturbance in the production of: A) Androgens B) Glucocorticoids C) Mineralocorticoids D) EstrogenMineralocorticoids such as aldosterone cause the kidneys to retain sodium ions. With sodium, water is also retained, elevating blood pressure. Absence of this hormone thus causes hypotension.6. The nurse is planning to teach the client about a spontaneous pneumothorax. The nurse would base the teaching on the understanding that: A) Inspired air will move from the lung into the pleural space. B) There is greater negative pressure within the chest cavity. C) The heart and great vessels shift to the affected side. D) The other lung will collapse if not treated immediately.As a person with a tear in the lung inhales, air moves through that opening into the intrapleural and causes partial or complete collapse of the lungs.7. During an assessment, the nurse recognizes that the client has an increased risk for developing cancer of the tongue. Which of the following health history will be a concern? A) Heavy consumption of alcohol. B) Frequent gum chewing. C) Nail biting. D) Poor dental habits.Heavy alcohol ingestion predisposes an individual to the development of oral cancer.8. The client in the orthopedic unit asks the nurse the reason behind why compact bone is stronger than cancellous bone. Which of the following is the correct response of the nurse? A) Compact bone is stronger than cancellous bone because of its greater size. B) Compact bone is stronger than cancellous bone because of its greater weight. C) Compact bone is stronger than cancellous bone because of its greater volume. D) Compact bone is stronger than cancellous bone because of its greater density.The greater the density of compact bone makes it stronger than the cancellous bone. Compact bone forms from cancellous bone by the addition of concentric rings of bones substances to the marrow spaces of cancellous bone. The large marrow spaces are reduced to haversian canals.9. The nurse is reviewing the laboratory results of the client. In reviewing the results of the RBC count, the nurse understands that the higher the red blood cell count, the : A) Greater the blood viscosity. B) Higher the blood pH. C) Less it contributes to immunity. D) Lower the hematocrit.Viscosity, a measure of a fluids internal resistance to flow, is increased as the number of red cells suspended in plasma.10. The physician advised the client with Hemiparesis to use a cane. The client asks the nurse why cane will be needed. The nurse explains to the client that cane is advised specifically to: A) Aid in controlling involuntary muscle movements. B) Relieve pressure on weight-bearing joints. C) Maintain balance and improve stability. D) Prevent further injury to weakened muscles.Hemiparesis creates instability. Using a cane provides a wider base of support and, therefore greater stability.11. The nurse is conducting a discharge teaching regarding the prevention of further problems to a client who undergone surgery for carpal tunnel syndrome of the right hand. Which of the following instruction will the nurse includes? A) Learn to type using your left hand only. B) Avoid typing in a long period of time. C) Avoid carrying heavy things using the right hand. D) Do manual stretching exercise during breaks.Manual stretching exercises will assist in keeping the muscles and tendons supple and pliable, reducing the traumatic consequences of repetitive activity.12. A female client is admitted because of recurrent urinary tract infections. The client asks the nurse why she is prone to this disease. The nurse states that the client is most susceptible because of: A) Continuity of the mucous membrane. B) Inadequate fluid intake. C) The length of the urethra. D) Poor hygienic practices.The length of the urethra is shorter in females than in males; therefore microorganisms have a shorter distance to travel to reach the bladder. The proximity of the meatus to the anus in females also increases this incidence.13. A 55-year-old client is admitted with chest pain that radiates to the neck, jaw and shoulders that occurs at rest, with high body temperature, weak with generalized sweating and with decreased blood pressure. A myocardial infarction is diagnosed. The nurse knows that the most accurate explanation for one of these presenting adaptations is: A) Catecholamines released at the site of the infarction causes intermittent localized pain. B) Parasympathetic reflexes from the infarcted myocardium causes diaphoresis. C) Constriction of central and peripheral blood vessels causes a decrease in blood pressure. D) Inflammation in the myocardium causes a rise in the systemic body temperature. Temperature may increase within the first 24 hours and persist as long as a week.14. Following an amputation of a lower limb to a male client, the nurse provides an instruction on how to prevent a hip flexion contracture. The nurse should instruct the client to:. A) Perform quadriceps muscle setting exercises twice a day. B) Sit in a chair for 30 minutes three times a day. C) Lie on the abdomen 30 minutes every four hours. D) Turn from side to side every 2 hours.The hips are in extension when the client is prone; this keeps the hips from flexing.15. The physician scheduled the client with rheumatoid arthritis for the injection of hydrocortisone into the knee joint. The client asks the nurse why there is a need for this injection. The nurse explains that the most important reason for doing this is to: A) Lubricate the joint. B) Prevent ankylosis of the joint. C) Reduce inflammation. D) Provide physiotherapy.Steroids have an anti-inflammatory effect that can reduce arthritic pannus formation.16. The nurse is assigned to care for a 57-year-old female client who had a cataract surgery an hour ago. The nurse should: A) Advise the client to refrain from vigorous brushing of teeth and hair. B) Instruct the client to avoid driving for 2 weeks. C) Encourage eye exercises to strengthen the ocular musculature. D) Teach the client coughing and deep-breathing techniques.Activities such as rigorous brushing of hair and teeth cause increased intraocular pressure and may lead to hemorrhage in the anterior chamber.17. A client with AIDS develops bacterial pneumonia is admitted in the emergency department. The clients arterial blood gases is drawn and the result is PaO2 80mmHg. then arterial blood gases are drawn again and the level is reduced from 80 mmHg to 65 mmHg. The nurse should; A) Have arterial blood gases performed again to check for accuracy. B) Increase the oxygen flow rate. C) Notify the physician. D) Decrease the tension of oxygen in the plasma.This decrease in PaO2 indicates respiratory failure; it warrants immediate medical evaluation.18. An 18-year-old college student is brought to the emergency department due to serious motor vehicle accident. Right above-knee-amputation is done. Upon awakening from surgery the client tells the nurse, What happened to me? I cannot remember anything? Which of the following would be the appropriate initial nursing response? A) You sound concerned; Youll probably remember more as you wake up. B) Tell me what you think happened. C) You were in a car accident this morning. D) An amputation of your right leg was necessary because of an accident.This is truthful and provides basic information that may prompt recollection of what happened; it is a starting point.19. A 38-year-old client with severe hypertension is hospitalized. The physician prescribed a Captopril (Capoten) and Alprazolam (Xanax) for treatment. The client tells the nurse that there is something wrong with the medication and nursing care. The nurse recognizes this behavior is probably a manifestation of the clients: A) Reaction to hypertensive medications. B) Denial of illness. C) Response to cerebral anoxia. D) Fear of the health problem.Clients adapting to illness frequently feel afraid and helpless and strike out at health team members as a way of maintaining control or denying their fear.20. Before discharge, the nurse scheduled the client who had a colostomy for colorectal cancer for discharge instruction about resuming activities. The nurse should plan to help the client understands that: A) After surgery, changes in activities must be made to accommodate for the physiologic changes caused by the operation. B) Most sports activities, except for swimming, can be resumed based on the clients overall physical condition. C) With counseling and medical guidance, a near normal lifestyle, including complete sexual function is possible. D) Activities of daily living should be resumed as quickly as possible to avoid depression and further dependency.There are few physical restraints on activity postoperatively, but the client may have emotional problems resulting from the body image changes.21. A client is scheduled for bariatric surgery. Preoperative teaching is done. Which of the following statement would alert the nurse that further teaching to the client is necessary? A) I will be limiting my intake to 600 to 800 calories a day once I start eating again. B) Im going to have a figure like a model in about a year. C) I need to eat more high-protein foods. D) I will be going to be out of bed and sitting in a chair the first day after surgery..clients need to be prepared emotionally for the body image changes that occur after bariatric surgery. Clients generally experience excessive abdominal skin folds after weight stabilizes, which may require a panniculectomy. Body image disturbance often occurs in response to incorrectly estimating ones size; it is not uncommon for the client to still feel fat no matter how much weight is lost.22. The client who had transverse colostomy asks the nurse about the possible effect of the surgery on future sexual relationship. What would be the best nursing response? A) The surgery will temporarily decrease the clients sexual impulses. B) Sexual relationships must be curtailed for several weeks. C) The partner should be told about the surgery before any sexual activity. D) The client will be able to resume normal sexual relationships.Surgery on the bowel has no direct anatomic or physiologic effect on sexual performance. However, the nurse should encourage verbalization.23. A 75-year-old male client tells the nurse that his wife has osteoporosis and asks what chances he had of getting also osteoporosis like his wife. Which of the following is the correct response of the nurse? A) This is only a problem for women. B) You are not at risk because of your small frame. C) You might think about having a bone density test, D) Exercise is a good way to prevent this problem.Osteoporosis is not restricted to women; it is a potential major health problem of all older adults; estimates indicate that half of all women have at least one osteoporitic fracture and the risk in men is estimated between 13% and 25%; a bone mineral density measurement assesses the mass of bone per unit volume or how tightly the bone is packed.24. An older adult client with acute pain is admitted in the hospital. The nurse understands that in managing acute pain of the client during the first 24 hours, the nurse should ensure that: A) Ordered PRN analgesics are administered on a scheduled basis. B) Patient controlled analgesia is avoided in this population. C) Pain medication is ordered via the intramuscular route. D) An order for meperidine (Demerol) is secured for pain relief. Around-the-clock administration of analgesics is recommended for acute pain in the older adult population; this help to maintain a therapeutic blood level of pain medication.25. A nurse is caring to an older adult with presbycusis. In formulating nursing care plan for this client, the nurse should expect that hearing loss of the client that is caused by aging to have: A) Overgrowth of the epithelial auditory lining. B) Copious, moist cerumen. C) Difficulty hearing womens voices. D) Tears in the tympanic membrane.Generally, female voices have a higher pitch than male voices; older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher-pitched sounds.26. The nurse is reviewing the clients chart about the ordered medication. The nurse must observe for signs of hyperkalemia when administering: A) Furosemide (Lasix) B) Hydrochlorothiazide (HydroDIURIL) C) Metolazone (Zaroxolyn) D) Spironolactone (Aldactone)Aldactone is a potassium-sparing diuretic; hyperkalemia is an adverse effect.27. The physician prescribed Albuterol (Proventil) to the client with severe asthma. After the administration of the medication the nurse should monitor the client for: A) Palpitation B) Visual disturbance C) Decreased pulse rate D) LethargyAlbuterols sympathomimetic effect causes cardiac stimulation that may cause tachycardia and palpitation.28. A client is receiving diltiazem (Cardizem). What should the nurse include in a teaching plan aimed at reducing the side effects of this medication? A) Take the drug with an antacid. B) Lie down after meals. C) Avoid dairy products in diet. D) Change positions slowly.Changing positions slowly will help prevent the side effect of orthostatic hypotension.29. A client is receiving simvastatin (Zocor). The nurse is aware that this medication is effective when there is decrease in: A) The triglycerides B) The INR C) Chest pain D) Blood pressureTherapeutic effects of simvastatin include decreased serum triglyceries, LDL and cholesterol.30. A client is taking nitroglycerine tablets, the nurse should teach the client the importance of: A) Increasing the number of tablets if dizziness or hypertension occurs. B) Limiting the number of tablets to 4 per day. C) Making certain the medication is stored in a dark container. D) Discontinuing the medication if a headache develops.Nitroglycerine is sensitive to light and moisture ad must be stored in a dark, airtight container.31. The physician prescribes Ibuprofen (Motrin) and hydroxychloroquine sulfate (Plaquenil) for a 58-year-old male client with arthritis. The nurse provides information about toxicity of the hydroxychloroquine. The nurse can determine if the information is clearly understood if the client states: A) I will contact the physician immediately if I develop blurred vision. B) I will contact the physician immediately if I develop urinary retention. C) I will contact the physician immediately if I develop swallowing difficulty. D) I will contact the physician immediately if I develop feelings of irritability.Visual disturbance are a sign of toxicity because retinopathy can occur with this drug.32. The client with an acute myocardial infarction is hospitalized for almost one week. The client experiences nausea and loss of appetite. The nurse caring for the client recognizes that these symptoms may indicate the: A) Adverse effects of spironolactone (Aldactone) B) Adverse effects of digoxin (Lanoxin) C) Therapeutic effects of propranolol (Indiral) D) Therapeutic effects of furosemide (Lasix)Toxic levels of Lanoxin stimulate the medullary chemoreceptor trigger zone, resulting in nausea and subsequent anorexia.33. A client with a partial occlusion of the left common carotid artery is scheduled for discharge. The client is still receiving Coumadin. The nurse provided a discharge instruction to the client regarding adverse effects of Coumadin. The nurse should tell the client to consult with the physician if: A) Swelling of the ankles increases. B) Blood appears in the urine. C) Increased transient Ischemic attacks occur. D) The ability to concentrate diminishes.Warfarin derivatives cause an increase in the prothrombin time and INR, leading to an increased risk for bleeding. Any abnormal or excessive bleeding must be reported, because it may indicate toxic levels of the drug.34. Levodopa is ordered for a client with Parkinsons disease. Before starting the medication, the nurse should know that: A) Levodopa is inadequately absorbed if given with meals. B) Levodopa may cause the side effects of orthostatic hypotension. C) Levodopa must be monitored by weekly laboratory tests. D) Levodopa causes an initial euphoria followed by depression.Levodopa is the metabolic precursor of dopamine. It reduces sympathetic outflow by limiting vasoconstriction, which may result in orthostatic hypotension.35. In making a diagnosis of myasthenia gravis Edrophonium HCI (Tensilon) is used. The nurse knows that this drug will cause a temporary increase in: A) Muscle strength B) Symptoms C) Blood pressure D) ConsciousnessTensilon, an anticholinesterase drug, causes temporary relief of symptoms of myasthenia gravis in client who have the disease and is therefore an effective diagnostic aid.36. The nurse can determine the effectiveness of carbamazepine (Tegretol) in the management of trigeminal neuralgia by monitoring the clients: A) Seizure activity B) Liver function C) Cardiac output D) Pain reliefCarbamazepine ( Tegretol) is administered to control pain by reducing the transmission of nerve impulses in clients with trigeminal neuralgia.37. Administration of potassium iodide solution is ordered to the client who will undergo a subtotal thyroidectomy. The nurse understands that this medication is given to: A) Ablate the cells of the thyroid gland that produce T4. B) Decrease the total basal metabolic rate. C) Decrease the size and vascularity of the thyroid. D) Maintain function of the parathyroid gland.Potassium iodide, which aids in decreasing the vascularity of the thyroid gland, decreases the risk for hemorrhage.38. A client with Addisons disease is scheduled for discharge. Before the discharge, the physician prescribes hydrocortisone and fludrocortisone. The nurse expects the hydrocortisone to: A) Increase amounts of angiotensin II to raise the clients blood pressure. B) Control excessive loss of potassium salts. C) Prevent hypoglycemia and permit the client to respond to stress. D) Decrease cardiac dysrhythmias and dyspnea.Hydrocortisone is a glucocorticoid that has anti-inflammatory action and aids in metabolism of carbohydrate, fat, and protein, causing elevation of blood glucose. Thus it enables the body to adapt to stress.39. A client with diabetes insipidus is taking Desmopressin acetate (DDAVP). To determine if the drug is effective, the nurse should monitor the clients: A) Arterial blood pH B) Pulse rate C) Serum glucose D) Intake and outputDDAVP replaces the ADH, facilitating reabsorption of water and consequent return of normal urine output and thirst.40. A client with recurrent urinary tract infections is to be discharged. The client will be taking nitrofurantoin (Macrobid) 50 mg po every evening at home. The nurse provides discharge instructions to the client. Which of the following instructions will be correct? A) Strain urine for crystals and stones B) Increase fluid intake. C) Stop the drug if the urinary output increases D) Maintain the exact time schedule for drug taking.To prevent crystal formation, the client should have sufficient intake to produce 1000 to 1500 mL of urine daily while taking this drug.41. A client with cancer of the lung is receiving chemotherapy. The physician orders antibiotic therapy for the client. The nurse understands that chemotherapy destroys rapidly growing leukocytes in the: A) Bone marrow B) Liver C) Lymph nodes D) BloodProlonged chemotherapy may slow the production of leukocytes in bone marrow, thus suppressing the activity of the immune system. Antibiotics may be required to help counter infections that the body can no longer handle easily.42. The physician reduced the clients Dexamethasone (Decadron) dosage gradually and to continue a lower maintenance dosage. The client asks the nurse about the change of dosage. The nurse explains to the client that the purpose of gradual dosage reduction is to allow: A) Return of cortisone production by the adrenal glands. B) Production of antibodies by the immune system C) Building of glycogen and protein stores in liver and muscle D) Time to observe for return of increases intracranial pressureAny hormone normally produced by the body must be withdrawn slowly to allow the appropriate organ to adjust and resume production.43. The nurse is assigned to care for a client with diarrhea. Excessive fluid loss is expected. The nurse is aware that fluid deficit can most accurately be assessed by: A) The presence of dry skin B) A change in body weight C) An altered general appearance D) A decrease in blood pressureDehydration is most readily and accurately measured by serial assessment of body weight; 1 L of fluid weighs 2.2 pounds.44. Which of the following is the most important electrolyte of intracellular fluid? A) Potassium B) Sodium C) Chloride D) CalciumThe concentration of potassium is greater inside the cell and is important in establishing a membrane potential, a critical factor in the cells ability to function.45. Which of the following client has a high risk for developing hyperkalemia? A) Crohns disease B) End-Stage renal disease C) Cushings syndrome D) Chronic heart failureThe kidneys normally eliminate potassium from the body; hyperkalemia may necessitate dialysis.46. The nurse is reviewing the laboratory result of the client. The clients serum potassium level is 5.8 mEq/L. Which of the following is the initial nursing action? A) Call the cardiac arrest team to alert them B) Call the laboratory and repeat the test C) Take the clients vital signs and notify the physician D) Obtain an ECG strip and have lidocaine availableVital signs monitor cardiorespiratory status; hyperkalemia causes serious cardiac dysrhythmias.47. Potassium chloride, 20 mEq, is ordered and to be added in the IV solution of a client in a diabetic ketoacidosis. The primary reason for administering this drug is: A) Replacement of excessive losses B) Treatment of hyperpnea C) Prevention of flaccid paralysis D) Treatment of cardiac dysrhythmiasOnce treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the cell, causing hypokalemia; therefore potassium, along with the replacement fluid, is generally supplied.48. A female client is brought to the emergency unit. The client is complaining of abdominal cramps. On assessment, client is experiencing anorexia and weight is reduced. The physicians diagnosis is colitis. Which of the following symptoms of fluid and electrolyte imbalance should the nurse report immediately? A) Skin rash, diarrhea, and diplopia B) Development of tetaniy with muscles spasms C) Extreme muscle weakness and tachycardia D) Nausea, vomiting, and leg and stomach cramps.Potassium, the major intracellular cation, functions with sodium and calcium to regulate neuromuscular activity and contraction of muscle fibers, particularly the heart muscle. In hypokalemia these symptoms develop.49. The client is to receive an IV piggyback medication. When preparing the medication the nurse should be aware that it is very important to: A) Use strict sterile technique B) Use exactly 100mL of fluid to mix the medication C) Change the needle just before adding the medication D) Rotate the bag after adding the medicationBecause IV solutions enter the bodys internal environment, all solutions and medications utilizing this route must be sterile to prevent the introduction of microbes.50. The nurse is reviewing the laboratory result of the client. An arterial blood gas report indicates the clients pH is 7.20, PCO2 35 mmHg and HCO3 is 19 mEq/L. The results are consistent with: A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosisA low pH and bicarbonate level are consistent with metabolic acidosis.

TEST VAll the questions in the quiz along with their answers are shown below. Your answers are bolded. The correct answers have a green background while the incorrect ones have a red background.1. A 17-year-old client has a record of being absent in the class without permission, and borrowing other peoples things without asking permission. The client denies stealing; rationalizing instead that as long as no one was using the items, there is no problem to use it by other people. It is important for the nurse to understand that psychodynamically, the behavior of the client may be largely attributed to a development defect related to the: A) Oedipal complex B) Superego C) Id D) EgoThis shows a weak sense of moral consciousness. According to Freudian theory, personality disorders stem from a weak superego.2. A client tells the nurse, Yesterday, I was planning to kill myself. What is the best nursing response to this cient? A) What are you going to do this time? B) Say nothing. Wait for the clients next comment C) You seem upset. I am going to be here with you; perhaps you will want to talk about it D) Have you felt this way before?The client needs to have his or her feelings acknowledged, with encouragement to discuss feelings, and be reassured about the nurses presence.3. In crisis intervention therapy, which of the following principle that the nurse will use to plan her/his goals? A) Crises are related to deep, underlying problems B) Crises seldom occur in normal peoples lives C) Crises may go on indefinitely. D) Crises usually resolved in 4-6 weeks.Part of the definition of a crisis is a time span of 4-6 weeks.4. The nurse enters the room of the male client and found out that the client urinates on the floor. The client hides when the nurse is about to talk to him. Which of the following is the best nursing intervention? A) Place restriction on the clients activities when his behavior occurs. B) Ask the client to clean the soiled floor. C) Take the client to the bathroom at regular intervals. D) Limit fluid intake.The client is most likely confused, rather than exhibiting acting-out, hostile behavior. Frequent toileting will allow urination in an appropriate place.5. A young lady with a diagnosis of schizophrenic reaction is admitted to the psychiatric unit. In the past two months, the client has poor appetite, experienced difficulty in sleeping, was mute for long periods of time, just stayed in her room, grinning and pointing at things. What would be the initial nursing action on admitting the client to the unit? A) Assure the client that You will be well cared for. B) Introduce the client to some of the other clients. C) Ask Do you know where you are? D) Take the client to the assigned room.The client needs basic, simple orientation that directly relates to the here-and-now, and does not require verbal interaction.6. A 16-year-old girl was diagnosed with anorexia. What would be the first assessment of the nurse? A) What food she likes. B) Her desired weight. C) Her body image. D) What causes her behavior.Although all options may appear correct. A is the best because it focuses on a range of possible positive reinforcers, a basis for an effective behavior modification program. It can lead to concrete, specific nursing interventions right away and provides a therapeutic use of control for the 16-year-old.7. On an adolescent unit, a nurse caring to a client was informed that her clients closest roommate dies at night. What would be the most appropriate nursing action? A) Do not bring it up unless the client asks. B) Tell the client that her roommate went home. C) Tell the client, if asked, You should ask the doctor. D) Tell the client that her closest roommate died.The nurse needs to wait and see: do not jump the gun; do not assume that the client wants to know now.8. A woman gave birth to an unhealthy infant, and with some body defects. The nurse should expect the womans initial reactions to include: A) Depression B) Withdrawal C) Apathy D) AngerThe woman is experiencing an actual loss and will probably exhibit many of the same symptoms as a person who has lost someone to death.9. A client in the psychiatric unit is shouting out loud and tells the nurse, Please, help me. They are coming to get me. What would be the appropriate nursing response? A) I wont let anyone get you. B) Who are they? C) I dont see anyone coming. D) You look frightened.This option is an example of pointing out reality- the nurses perception.10. A client who is severely obese tells the nurse, My therapist told me that I eat a lot because I didnt get any attention and love from my mother. What does the therapist mean? What is the best nursing response? A) What do you think is the connection between your not getting enough love and overeating? B) Tell me what you think the therapist means. C) You need to ask your therapist. D) We are here to deal with your diet, not with your psychological problems.This response asks information that the nurse can use. If the client understands the statement, the nurse can support the therapist when focusing on connection between food, love, and mother. If the client does not understand the statement, the nurse can help get clarification from the therapist.11. After the discussion about the procedure the physician scheduled the client for mastectomy. The client tells the nurse, If my breasts will be removed, Im afraid my husband will not love me anymore and maybe he will never touch me. What should the nurses response? A) I doubt that he feels that way. B) What makes you feel that way? C) Have you discussed your feelings with your husband? D) Ask the husband, in front of the wife, how he feels about this.This option redirects the client to talk to her husband.12. The child is brought to the hospital by the parents. During assessment of the nurse, what parental behavior toward a child should alert the nurse to suspect child abuse? A) Ignoring the child. B) Flat affect. C) Expressions of guilt. D) Acting overly solicitous toward the childThis is an example of reaction formation, a coping mechanism.13. A nurse is caring to a client with manic disorder in the psychiatric ward. On the morning shift, the nurse is talking with the client who is now exhibiting a manic episode with flight of ideas. The nurse primarily needs to: A) Focus on the feelings conveyed rather than the thoughts expressed. B) Speak loudly and rapidly to keep the clients attention, because the client is easily distracted. C) Allow the client to talk freely. D) Encourage the client to complete one thought at a time.Often the verbalized ideas are jumbled, but the underlying feelings are discernible and must be acknowledged.14. The nurse is caring to an autistic child. Which of the following play behavior would the nurse expect to see in a child? A) competitive play B) nonverbal play C) cooperative play D) solitary playAutistic children do best with solitary play because they typically do not interact with others in a socially comprehensible and acceptable way.15. The client is telling the nurse in the psychiatric ward, I hate them. Which of the following is the most appropriate nursing response to the client? A) Tell me about your hate. B) I will stay with you as long as you feel this way. C) For whom do you have these feelings? D) I understand how you can feel this way.The nurse is asking the client to clarify and further discuss feelings.16. The mother visits her son with major depression in the psychiatric unit. After the conversation of the client and the mother, the nurse asks the mother how it is talking to her son. The mother tells the nurse that it was a stressful time. During an interview with the client, the client says, we had a marvelous visit. Which of the following coping mechanism can be described to the statement of the client? A) Identification. B) Rationalization. C) Denial. D) Compensation.Denial is the act of avoiding disagreeable realities by ignoring them.17. A male client is quiet when the physician told him that he has stage IV cancer and has 4 months to live. The nurse determines that this reaction may be an example of: A) Indifference B) Denial C) Resignation D) AngerReactions when told of a life-threatening illness stem from Kbler-Ross ideas on death and dying. Denial is a typical grief response, and usually is a first reaction.18. A nurse is caring to a female client with five young children. The family member told the client that her ex-husband has died 2 days ago. The reaction of the client is stunned silence, followed by anger that the ex-husband left no insurance money for their young children. The nurse should understand that: A) The children and the injustice done to them by their fathers death are the womans main concern. B) To explain the womans reaction, the nurse needs more information about the relationship and breakup. C) The woman is not reacting normally to the news. D) The woman is experiencing a normal bereavement reaction.Shock and anger are commonly the primary initial reactions.19. A client who is manic comes to the outpatient department. The nurse is assigning an activity for the client. What activity is best for the nurse to encourage for a client in a manic phase? A) Solitary activity, such as walking with the nurse, to decrease stimulation. B) Competitive activity, such as bingo, to increase the clients self-esteem. C) Group activity, such as basketball, to decrease isolation. D) Intellectual activity, such as scrabble, to increase concentration.This option avoids external stimuli, yet channels the excess motor activity that is often part of the manic phase.20. The nurse is about to administer Imipramine HCI (Tofranil) to the client, the client says, Why should I take this? The doctor started me on this 10days ago; it didnt help me at all. Which of the following is the best nursing response: A) What were you expecting to happen? B) It usually takes 2-3 weeks to be effective. C) Do you want to refuse this medication? You have the right. D) Thats a long time wait when you feel so depressed.The patient needs a brief, factual answer.21. Which of the following drugs the nurse should choose to administer to a client to prevent pseudoparkinsonism? A) Isocarboxazid (Marplan) B) Chlorpromazine HCI (Thorazine) C) Trihexyphenidyl HCI (Artane) D) Trifluoperazine HCI (Stelazine)Trihexyphenidyl HCI (Artane) is often used to counteract side effect of pseudoparkinsonism, which often accompanies the use of phenothiazine, such as chlorpromazine HCI (Thorazine or Trifluoperazine HCI (Stelazine).22. The nurse is caring to an 80-year-old client with dementia? What is the most important psychosocial need for this client? A) Focus on the there-and-then rather the here-and-now. B) Limit in the number of visitors, to minimize confusion. C) Variety in their daily life, to decrease depression. D) A structured environment, to minimize regressive behaviors.Persons with dementia needs sameness, consistency, structure, routine, and predictability.23. A client tells the nurse, I dont want to eat any meals offered in this hospital because the food is poisoned. The nurse is aware that the client is expressing an example of: A) Delusion. B) Hallucination. C) Negativism. D) Illusion.This is a false belief developed in response to an emotional need.24. A client is admitted in the hospital. On assessment, the nurse found out that the client had several suicidal attempts. Which of the following is the most important nursing action? A) Ignore the client as long as he or she is talking about suicide, because suicide attempt is unlikely. B) Administer medication. C) Relax vigilance when the client seems to be recovering from depression. D) Maintain constant awareness of the clients whereabouts.The client must be constantly observed.25. The nurse suspects that the client is suffering from depression. During assessment, what are the most characteristic signs and symptoms of depression the nurse would note? A) Constipation, increased appetite. B) Anorexia, insomnia. C) Diarrhea, anger. D) Verbosity, increased social interaction.The appetite is diminished and sleeping is affected to a client with depression.26. The client in the psychiatric unit states that, The goodas are coming! I must be ready. In response to this neologism, the nurses initial response is to: A) Acknowledge that the word has some special meaning for the client. B) Try to interpret what the client means. C) Divert the clients attention to an aspect of reality. D) State that what the client is saying has not been understood and then divert attention to something that is really bound.It is important to acknowledge a statement, even if it is not understood.27. A male client diagnosed with depression tells the nurse, I dont want to look weak and I dont even cry because my wife and my kids cant bear it. The nurse understands that this is an example of: A) Repression. B) Suppression. C) Undoing. D) Rationalization.Rationalization is the process of constructing plausible reasons for ones responses.28. A female client tells the nurse that she is afraid to go out from her room because she thinks that the other client might kill her. The nurse is aware that this behavior is related to: A) Hallucination. B) Ideas of reference. C) Delusion of persecution. D) Illusion. The client has ideas that someone is out to kill her.29. A female client is taking Imipramine HCI (Tofranil) for almost 1 week and shows less awareness of the physical body. What problem would the nurse be most concerned? A) Nausea. B) Gait disturbances. C) Bowel movements. D) Voiding.A serious side effect of Imipramine HCI (Tofranil) is urinary retention (voiding problems)30. A 6-year-old client dies in the nursing unit. The parents want to see the child. What is the most appropriate nursing action? A) Give the parents time alone with the body. B) Ask the physician for permission. C) Complete the postmortem care and quietly accompany the family to the childs room. D) Suggest the parents to wait until the funeral service to say good-bye.This allows the parents/family to grieve over the loss of the child, by going through the steps of leave taking.31. A 20-year-old female client is diagnosed with anxiety disorder. The physician prescribed Flouxetine (Prozac). What is the most important side effects should a nurse be concerned? A) Tremor, drowsiness. B) Seizures, suicidal tendencies. C) Visual disturbance, headache. D) Excessive diaphoresis, diarrhea.Assess for suicidal tendencies, especially during early therapy. There is an increased risk of seizures in debilitated client and those with a history of seizures.32. A nurse is assigned to activate a client who is withdrawn, hears voices and negativistic. What would be the best nursing approach? A) Mention that the voices would want the client to participate. B) Demand that the client must join a group activity. C) Give the client a long explanation of the benefits of activity. D) Tell the client that the nurse needs a partner for an activity.The nurse helps to activate by doing something with the client.33. A nurse is going to give a rectal suppository as a preoperative medication to a 4-year-old boy. The boy is very anxious and frightened. Which of the following statement by the nurse would be most appropriate to gain the childs cooperation? A) Be a big kid! Everyones waiting for you. B) Lie still now and Ill let you have one of your presents before you even have your operation. C) Take a nice, big, deep breath and then let me hear you count to five. D) You look so scared. Want to know a secret? This wont hurt a bit! Preschool children commonly experience fears and fantasies regarding invasive procedures. The nurse should attempts to momentarily distract the child with a simple task that can be easily accomplished while the child remains in the side-lying position. The suppository can be slipped into place while the child is counting, and then the nurse can praise the child for cooperating, while holding the buttocks together to prevent expulsion of the suppository.34. A depressed client is on an MAO inhibitor? What should the nurse watch out for? A) Hypertensive crisis. B) Diet restrictions. C) Taking medication with meals. D) Exposure to sunlight.This is the more inclusive answer, although diet restrictions (answer1) are important, their purpose is to prevent hypertensive crisis (answer 2).35. A 16-year-old girl is admitted for treatment of a fracture. The client shares to the nurse caring to her that her step-father has made sexual advances to her. She got the chance to tell it to her mother but refuses to believe. What is the most therapeutic action of the nurse would be: A) Tell the client to work it out with her father. B) Tell the client to discuss it with her mother. C) Ask the father about it. D) Ask the mother what she thinks.This comes closest to beginning to focus on family-centered approach to intervene in the conspiracy of silence. This is therefore the best among the options.36. A client with a diagnosis of paranoid disorder is admitted in the psychiatric hospital. The client tells the nurse, the FBI is following me. These people are plotting against me. With this statement the nurse will need to: A) Acknowledge that this is the clients belief but not the nurses belief. B) Ask how that makes the client feel. C) Show the client that no one is behind. D) Use logic to help the client doubt this belief.The nurse should neither challenge nor use logic to dispel an irrational belief.37. A nurse is completing the routine physical examination to a healthy 16-year-old male client. The client shares to the nurse that he feels like killing his girlfriend because he found out that her girlfriend had another boyfriend. He then laughs, and asks the nurse to keep this a secret just between the two of them. The nurse reviews his chart and notes that there is no previously history of violence or psychiatric illness. Which of the following would be the best action of the nurse to take at this time? A) Suggest the teen meet with a counselor to discuss his feelings about his girlfriend. B) Tell the teen that his feelings are normal, and recommend that he find another girlfriend to take his mind off the problem. C) Recall the teenage boys often say things they really do not mean and ignore the comment. D) Regard the comment seriously and notify the teens primary health care provider and parentsAny threat to the safety of oneself or other should always be taken seriously and never disregarded by the nurse.38. Which of the following person will be at highest risk for suicide? A) A student at exam time B) A married woman, age 40, with 6 children. C) A person who is an alcoholic. D) A person who made a previous suicide attempt.The likelihood of multiple contributing factors may make this person at higher risk for suicide. Some factors that may exist are physical illness related to alcoholism, emotional factors ( anxiety, guilt, remorse), social isolation due to impaired relationships and economic problems related to employment.39. A male client is repetitively doing the handwashing every time he touches things. It is important for a nurse to understand that the clients behavior is probably an attempt to: A) Seek attention from the staff. B) Control unacceptable impulses or feelings. C) Do what the voices the patient hears tell him or her to do. D) Punish himself or herself for guilt feeling.A ritual, such as compulsive handwashing, is an attempt to allay anxiety caused by unconscious impulses that are frightening.40. In a mental health settings, the basic goal of nursing is to: A) Advance the science of psychiatry by initiating research and gathering data for current statistics on emotional illness. B) Plan activity programs for clients. C) Understand various types of family therapy and psychological tests and how to interpret them. D) Maintain a therapeutic environment.This is the most neutral answer by process of elimination.41. A 3-year-old boy is brought to the emergency department. After an hour, the boy dies of respiratory failure. The mother of the boy becomes upset, shouting and abusive, saying to the nurse, If it had been your son, they would have done more to save it. What should the nurse say or do? A) Touch her and tell her exactly what was done for her baby. B) Allow the mother to continue her present behavior while sitting quietly with her. C) No, all clients are given the same good care. D) Yes, youre probably right. Your son did not get better care.This option allows a normal grief response (anger).42. The nurse is interacting to a client with an antisocial personality disorder. What would be the most therapeutic approach of the nurse to an antisocial behavior? A) Gratify the clients inner needs. B) Give the client opportunities to test reality. C) Provide external controls. D) Reinforce the clients self-concept.Personality disorders stem from a weak superego, implying a lack of adequate controls.43. A 55-year-old male client tells the nurse that he needs his glasses and hearing aid with him in the recovery room after the surgery, or he will be upset for not granting his request. What is the appropriate nursing response? A) Do you get upset and confused often? B) You wont need your glasses or hearing aid. The nurses will take care of you. C) I understand. You will be able to cooperate best if you know what is going on, so I will find out how I can arrange to have your glasses and hearing aid available to you in the recovery room. D) I understand you might be more cooperative if you have your aid and glasses, but that is just not possible. Rules, you know.The client will be easier to care for if he has his hearing aid and glasses.44. The male client had fight with his roommates in the psychiatric unit. The client agitated client is placed in isolation for seclusion. The nurse knows it is essential that: A) A staff member has frequent contacts with the client. B) Restraints are applied. C) The client is allowed to come out after 4 hours. D) All the furniture is removed form the isolation room.Frequent contacts at times of stress are important, especially when a client is isolated.45. A medical representative comes to the hospital unit for the promotion of a new product. A female client, admitted for hysterical behavior, is found embracing him. What should the nurse say? A) Have you considered birth control? B) This isnt the purpose of either of you being here. C) I see youve made a new friend. D) Think about what you are doing.This response is aimed at redirecting the inappropriate behavior.46. A client with dementia is for discharge. The nurse is providing a discharge instruction to the family member regarding safety measures at home. What suggestion can the nurse make to the family members? A) Avoid stairs without banisters. B) Use restraints while the client is in bed to keep him or her from wandering off during the night. C) Use restraints while the client is sitting in a chair to keep him or her from wandering off during the day. D) Provide a night-light and a big clock.This option is best to decrease confusion and disorientation to place and time.47. A 30-year-old married woman comes to the hospital for treatment of fractures. The woman tells the nurse that she was physically abused by her husband. The woman receives a call from her husband telling her to get home and things will be different. He felt sorry of what he did. What can the nurse advise her? A) Do you think so? B) Its not likely. C) What will be different? D) I hope so, for your sake.This option helps the woman to think through and elaborate on her own thoughts and prognosis.48. A female client was diagnosed with breast cancer. It is found to be stage IV, and a modified mastectomy is performed. After the procedure, what behaviors could the nurse expects the client to display? A) Denial of the possibility of carcinoma. B) Signs of grief reaction. C) Relief that the operation is over. D) Signs of deep depression.It is mostly likely that grief would be expressed because of object loss.49. A client is withdrawn and does not want to interact to anybody even to the nurse. What is the best initial nursing approach to encourage communication with this client? A) Use simple questions that call for a response. B) Encourage discussion of feelings. C) Look through a photo album together. D) Bring up neutral topics.Neutral, nonthreatening topics are best in attempting to encourage a response.50. Which of the following nursing approach is most important in a client with depression? A) Deemphasizing preoccupation with elimination, nourishment, and sleep. B) Protecting against harm to others. C) Providing motor outlets for aggressive, hostile feelings. D) Reducing interpersonal contacts.It is important to externalize the anger away from self.