Download - Medical-Surgical for Midterm (Answers)

8/12/2019 Medical-Surgical for Midterm (Answers)

1/43


2/43

cardiomyopathy indicates constrictive pericarditis; the underlying cause is usuallymyocardial.

Source:

3. Which of the following groups of symptoms indicated a ruptured abdominalaneurysm?

Stem:

Answer: (B) Severe lower back pain, decreased BP, decreased RBC, increased WBC

Rationale: Severe lower back pain indicates an aneurysm rupture, secondary topressure being applied within the abdominal cavity. When rupture occurs, thepain is constant because it cant be alleviated until the aneurysm is repaired.Blood pressure decreases due to the loss of blood. After the aneurysm ruptures,

the vasculature is interrupted and blood volume is lost, so blood pressurewouldnt increase. For the same reason, the RBC count is decreased notincrease. The WBC count increases as cells migrate to the site of injury.

Distractor: ()

Rationale:

Source:

4. Which of the following treatments is the definitive one for a rupturedaneurysm?

Stem:

Answer: (D) Surgical intervention

Rationale: When the vessel ruptures, surgery is the only intervention that canrepair it.

Distractor: ()

Rationale: Administration of antihypertensive medications and beta-adrenergicblockers can help control hypertension, reducing the risk of rupture. Anaortogram is a diagnostic tool used to detect an aneurysm.

Source:

5. What is the term used to describe an enlargement of the heart muscle?


3/43


4/43

Rationale: Crackles are indicative of fluid in the lungs. Dullness is heard oversolid organs, such as the liver. Friction rubs indicate inflammation of theperitoneal surface.

Source:

8. Which of the following cardiac conditions does a fourth heart sound (S4)indicate?

Stem:

Answer: (D)Failure of the ventricle to eject all the blood during systole

Rationale:An S4 occurs as a result of increased resistance to ventricular fillingafter atrial contraction. This increased resistance is related to decreasecompliance of the ventricle.

Distractor: ()

Rationale: A dilated aorta doesnt cause an extra heart sound, though it doescause a murmur. Decreased myocardial contractility is heard as a third heartsound. An s4 isnt heard in a normally functioning heart.

Source:

9. Which of the following classes of medications maximizes cardiac performancein clients with heat failure by increasing ventricular contractility?

Stem:

Answer: (D)Inotropic agents

Rationale: Inotropic agents are administered to increase the force of the heartscontractions, thereby increasing ventricular contractility and ultimately increasingcardiac output.

Distractor: ()

Rationale: Beta-adrenergic blockers and calcium channel blockers decrease theheart rate and ultimately decrease the workload of the heart. Diuretics areadministered to decrease the overall vascular volume, also decreasing theworkload of the heart.

Source:

10. Which of the following arteries primarily feeds the anterior wall of the heart?


5/43

Stem:

Answer: (C) Left anterior descending artery

Rationale: The left anterior descending artery is the primary source of blood forthe anterior wall of the heart.

Distractor: ()

Rationale: The circumflex artery supplies the lateral wall, the internal mammaryartery supplies the mammary, and the right coronary artery supplies the inferiorwall of the heart.

Sources:

11. Which of the following blood tests is most indicative of cardiac damage?

Stem:

Answer: (C) Troponin I

Rationale: Troponin I levels rise rapidly and are detectable within 1 hour ofmyocardial injury. Troponin I levels arent detectable in people without cardiacinjury.

Distractor: ()

Rationale: Lactate dehydrogenase is present in almost all body tissues and notspecific to heart muscle. LDH isoenzymes are useful in diagnosing cardiac injury.CBC is obtained to review blood counts, and a complete chemistry is obtained toreview electrolytes. Because CK levels may rise with skeletal muscle injury, CKisoenzymes are required to detect cardiac injury.

Source:

12. Medical treatment of coronary artery disease includes which of the followingprocedures?

Stem:

Answer: (C) Oral medication administration

Rationale: Oral medication administration is a noninvasive, medical treatment forcoronary artery disease.


6/43


7/43

Stem:

Answer: (C) Faces pain-rating scale

Rationale: The Faces pain rating scale (depicting smiling, neutral, frowning,

crying, etc.) is appropriate for young children who may have difficulty describingpain or understanding the correlation of pain to numerical or verbal descriptors.

Distractor: ()

Rationale: The other tools require abstract reasoning abilities to make analogiesand use of advanced vocabulary.

Source:

16. The leader of the study knows that certain patients who are in a specializedresearch setting tend to respond psychologically to the conditions of the study.This is referred to as:

Stem: ResearchAnswer: (B)Hawthorne effect

Rationale:Hawthorne effect is based on the study by Elton Mayo and companyabout the effect of an intervention done to improve the working conditions of theworkers on their productivity. It resulted to an increased productivity but not dueto the intervention but due to the psychological effects of being observed. Theyperformed differently because they were under observation.

Distractor: (A) Cause and Effect

Rationale: Cause and Effect is the manipulation of one variable causing achange to occur in another variable.

Source:http://answers.yahoo.com/question/index?qid=20091004231414AAxvKGD

17. Family members are encouraging your client to tough it out rather than runthe risk of becoming addicted to narcotics. The client is stoically abiding by thefamilys wishes. Priority nursing interventions for this client should target whichdimension of pain?

Stem:

Answer: (C) Sociocultural


8/43

Rationale: The family is part of the sociocultural dimension of pain. They areinfluencing the client should be included in the teaching sessions about theappropriate use of narcotics and about the adverse effects of pain on the healingprocess.

Distractor: ()

Rationale: The other dimensions should be included to help the client/familyunderstand overall treatment plan and pain mechanism.

18. As the charge nurse, you are reviewing the charts of clients who wereassigned to a newly graduated RN. The RN has correctly charted dose and time ofmedication, but there is no documentation regarding non-pharmaceuticalmeasures. What action should you take first?

Stem:

Answer: (D)Give praise for the correct dose and time and discuss the deficits incharting.

Rationale: In supervising the new RN, good performance should be reinforcedfirst and then areas of improvement can be addressed.

Distractor: ()

Rationale: Asking the nurse about knowledge of pain management is also anoption; however, it would be a more indirect and time-consuming approach.Making a note and watching do not help the nurse to correct the immediateproblem. In-service might be considered if the problem persists.

Source:

19. On admission to the emergency department the burned clients bloodpressure is 90/60, with an apical pulse rate of 122. These findings are an expectedresult of what thermal injuryrelated response?

Stem:

Answer: (A)Fluid shift

Rationale: The physiologic effect of histamine release in injured tissues is a lossof vascular volume to the interstitial space, with a resulting decrease in bloodpressure.

Distractor: ()


9/43

Rationale: Intense pain and carbon monoxide poisoning increase bloodpressure. Hemorrhage is unusual in a burn injury.

Source:

20. A client is being tapered off opioids and the nurse is watchful for signs ofwithdrawal. What is one of the first signs of withdrawal?

Stem:

Answer: (C)Diaphoresis

Rationale: Diaphoresis is one of the early signs that occur between 6 and 12hours.

Distractor: ()

Rationale: Fever, nausea, and abdominal cramps are late signs that occurbetween 48 and 72 hours.

Source:

21. A tearful parent brings a child to the ED for taking an unknown amount ofchildrens chewable vitamins at an unknown time. The child is currently alert andasymptomatic. What information should be immediately reported to thephysician?

Stem:

Answer: (A)The ingested childrens chewable vitamins contain iron.

Rationale: Iron is a toxic substance that can lead to massive hemorrhage, coma,shock, and hepatic failure. Deferoxame is an antidote that can be used for severecases of iron poisoning.

Distractor: ()

Rationale: Other information needs additional investigation, but will not changethe immediate diagnostic testing or treatment plan.

Source:

22. When an unexpected death occurs in the ED, which of the following tasks ismost appropriate to delegate to the nursing assistant?


10/43


11/43

Distractor: (D) Release findings only to the participants of the study

Rationale: Releasing the findings only to the participants of the study does notensure their anonymity rather it serves as a sign that they are one of the

participants of the study.

25. The burned client newly arrived from an accident scene is prescribed toreceive 4 mg of morphine sulfate by IV push. What is the most important reasonto administer the opioid analgesic to this client by the intravenous route?

Stem:

Answer: (C) The danger of an overdose during fluid remobilization is reduced.

Rationale:Although providing some pain relief has a high priority, and giving thedrug by the IV route instead of IM, SC, or orally does increase the rate of effect,the most important reason is to prevent an overdose from accumulation of drugin the interstitial space during the fluid shift of the emergent phase. When edemais present, cumulative doses are rapidly absorbed when the fluid shift isresolving. This delayed absorption can result in lethal blood levels of analgesics.

Distractor: ()

Rationale:

Source:

26. The burned client is ordered to receive intravenous cimetidine, an H2histamine blocking agent, during the emergent phase. When the clients familyasks why this drug is being given, what is the nurses best response?

Stem:

Answer: (C)To decrease hydrochloric acid production in the stomach and preventulcers.

Rationale: Ulcerative gastrointestinal disease may develop within 24 hours aftera severe burn as a result of increased hydrochloric acid production anddecreased mucosal barrier. Cimetidine inhibits the production and release ofhydrochloric acid.

Distractor: ()

Rationale:


12/43

Source:

27. The physician has ordered cooling measures for a child with fever who islikely to be discharged when the temperature comes down. Which of the

following would be appropriate to delegate to the nursing assistant?

Stem:

Answer: (A)Assist the child to remove outer clothing.

Rationale: The nursing assistant can assist with the removal of the outerclothing, which allows the heat to dissipate from the childs skin.

Distractor: ()

Rationale: Advising and explaining are teaching functions that are theresponsibility of the RN. Tepid baths are not usually performed because ofpotential for rebound and shivering.

Source:

28. What clinical manifestation indicates that an escharotomy is needed on acircumferential extremity burn?

Stem:

Answer: (C) Capillary refill is slow in the digits and the distal pulse is absent.

Rationale: Circumferential eschar can act as a tourniquet when edema formsfrom the fluid shift, increasing tissue pressure and preventing blood flow to thedistal extremities and increasing the risk for tissue necrosis. This problem is anemergency and, without intervention, can lead to loss of the distal limb. Thisproblem can be reduced or corrected with an escharotomy.

Distractor: ()

Rationale:

29. Which type of fluid should the nurse expect to prepare and administer as fluidresuscitation during the emergent phase of burn recovery?

Stem:

Answer: (B) Crystalloids


13/43


14/43

through burn wounds to affect kidney function. Any client receiving gentamicin byany route should have kidney function monitored.

Distractor: ()

Rationale:

Source:999932. Nurse Angela is caring for a client who has been treated long term withantipsychotic medication. During the assessment, Nurse Angela checks the clientfor tardive dyskinesia. If tardive dyskinesia is present, Nurse Angela would mostlikely observe:

Stem: Tardive dyskinesiaAnswer: (A)Abnormal movements and involuntary movements of the mouth, tongue,

and face.

Rationale: Tardive dyskinesia is a severe reaction associated with long term useof antipsychotic medication. The clinical manifestations include abnormalmovements (dyskinesia) and involuntary movements of the mouth, tongue (flycatcher tongue), and face.

Distractor: (D) Severe headache, flushing, tremors, and ataxia

Rationale: Ataxia, flushing, tremors are not included in the signs of Tardivedyskinesia.

Source:http://en.wikipedia.org/wiki/Tardive_dyskinesia

33. After seeking help at an outpatient mental health clinic, Ruby who was rapedwhile walking her dog is diagnosed with post-traumatic stress disorder (PTSD).Three months later, Ruby returns to the clinic, complaining of fear, loss ofcontrol, and helpless feelings. Which nursing intervention is most appropriate forRuby?

Stem: Post-traumatic Stress DisorderAnswer: (D)Exploring the meaning of the traumatic event with the client.

Rationale: The client with PTSD needs encouragement to examineand understand the meaning of the traumatic event and consequentlosses. Otherwise, symptoms may worsen and the client may becomedepressed or engage in self-destructive behavior such as substance abuse.

Distractor: (A) Recommending a high-protein, low-fat diet.


15/43

Rationale: The client must explore the meaning of the event and wont healwithout this, no matter how much time passes. Behavioral techniques, suchas relaxation therapy, may help decrease the clients anxiety and inducesleep.The physician may prescribe anti-anxiety agents or antidepressants cautiously to

avoid dependence; sleep medication is rarely appropriate. A special diet isntindicated unless the client also has an eating disorder or a nutritional problem.

Source:http://en.wikipedia.org/wiki/Posttraumatic_stress_disorder

34. Jessica with manic episodes is taking lithium. Which electrolyte level shouldthe nurse check before administering this medication?

Stem: LithiumAnswer: (B)Sodium

Rationale: Lithium is chemically similar to sodium. If sodium levels are reduced,such as from sweating or diuresis, lithium will be reabsorbed by the kidneys,increasing the risk of toxicity. Clients taking lithium shouldnt restrict their intakeof sodium and should drink adequate amounts of fluid each day. The otherelectrolytes are important for normal body functions but sodium is most importantto the absorption of lithium.

Distractor: (D) Potassium

Rationale: Potassium has an inverse relationship with Sodium

Source:http://en.wikipedia.org/wiki/Lithiumhttp://www.medscape.com/viewarticle/759042

35. Nurse Angela develops methods for data gathering. Which of the followingcriteria of a good instrument refers to the ability of the instrument to yield thesame results upon its repeated administration?

Stem: Criteria of a good data gathering instrumentAnswer: (D) Reliability

Rationale: Reliability is consistency of the research instrument. It refers to therepeatability of the instrument in extracting the same responses upon itsrepeated administration.

Distractor: (B) Specificity
http://en.wikipedia.org/wiki/Lithiumhttp://en.wikipedia.org/wiki/Lithium


16/43

Rationale: Specificity is the probability in a binary test, of a true negative beingcorrectly identified.

Source:http://en.wiktionary.org/wiki/specificity

36. A dying male client gradually moves toward resolution of feelings regardingimpending death. Basing care on the theory of Kubler-Ross, Nurse Angela plansto use nonverbal interventions when assessment reveals that the client is in the:

Stem: Stages of GriefAnswer: (D)Acceptance stage

Rationale: Communication and intervention during this stage aremainly nonverbal, as when the client gestures to hold the nurses hand.

Distractor: (B) Denial stage

Rationale: The client is already moving towards a resolution of his feelingstowards dying.

Source:http://en.wikipedia.org/wiki/K%C3%BCbler-Ross_model

37. Nurse Angela develops a countertransference reaction. This is evidenced by:

Stem: Countertransference reactionAnswer: (A)Revealing personal information to the client

Rationale: Countertransference is an emotional reaction of the nurse on theclient based on her unconscious needs and conflicts.

Distractor: (D) The client feels angry towards the nurse who resembles his mother.

Rationale: B and C are therapeutic approaches. While option D is transferencereaction where a client has an emotional reaction towards the nurse based onher past.

Source:http://en.wikipedia.org/wiki/Countertransference

38. An 83 year-old male client is in extended care facility is anxious most of thetime and frequently complains of a number of vague symptoms that interfere withhis ability to eat. These symptoms indicate which of the following disorders?

Stem: Eating disturbance


17/43


18/43

Distractor: (D) Ive lost my phobia for water.

Rationale: MAO inhibitors arent used to help control flashbacks or phobias or todecrease the craving for alcohol.

Source:http://en.wikipedia.org/wiki/Monoamine_oxidase_inhibitor

41. Nurse Angela is caring for a client diagnosed with bulimia. The mostappropriate initial goal for a client diagnosed with bulimia is to:

Stem: BulimiaAnswer: (C)Identify anxiety-causing situations

Rationale: Bulimic behavior is generally a maladaptive coping response to stressand underlying issues. The client must identify anxiety-causing situations that

stimulate the bulimic behavior and then learn new ways ofcoping with the anxiety.

Distractor: (B) Control eating impulses

Rationale: You cannot control the clients eating impulses unless you haveidentified the cause of the clients anxiety.

Source:http://en.wikipedia.org/wiki/Bulimia_nervosa

42. The psychiatrist orders lithium carbonate 600 mg P.O. T.I.D. for a femaleclient. Nurse Angela would be aware that the teaching about the side effects ofthis drug was understood when the client state, I will call my doctor immediatelyif I notice any:

Stem: Side effects of Lithium CarbonateAnswer: (B)Fine hand tremors or slurred speech

Rationale: These are common side effects of lithium carbonate.

Distractor: (A) Sensitivity to bright light or sun

Rationale: Medications that causes sensitivity to heat or sun are anti-psychoticdrugs such as Haldol.

Source:http://en.wikipedia.org/wiki/Lithiumhttp://www.mindlink.org/meds_sensitivity.html


19/43

43. Nurse Angela would expect that a client with vascular dementia wouldexperience:

Stem: Vascular dementiaAnswer: (D)Disturbance in recalling recent events related to cerebral hypoxia.

Rationale: Cell damage seems to interfere with registering input stimuli, whichaffects the ability to register and recall recent events; vascular dementia isrelated to multiple vascular lesions of the cerebral cortex and subcorticalstructure.

Distractor: (B). Loss of abstract thinking related to emotional state

Rationale: Loss of thinking related to emotional state is not in connection withthe question.

Source:http://www.alz.org/dementia/vascular-dementia-symptoms.asp

44. Jessica is diagnosed with panic disorder with agoraphobia is talking with thenurse in-charge about the progress made in treatment. Which of the followingstatements indicates a positive client response?

Stem:AgoraphobiaAnswer: (A)I went to the mall with my friends last Saturday

Rationale: Clients with panic disorder tend to be socially withdrawn. Going to themall is a sign of working on avoidance behaviors.

Distractor: (C) Today I decided that I can stop taking my medication

Rationale: Hyperventilating is a key symptom of panic disorder. Teachingbreathing control is a major intervention for clients with panic disorder. The clienttaking medications for panic disorder; such as tricylic antidepressants andbenzodiazepines must be weaned off these drugs. Most clients with panicdisorder with agoraphobia dont have nutritional problems.

Source:http://www.medicalnewstoday.com/articles/162169.php

45. Nurse Angela enters a clients room, the client says, Theyre crawling on mysheets! Get them off my bed! Which of the following assessment is the mostaccurate?

Stem: Visual disturbance
http://www.alz.org/dementia/vascular-dementia-symptoms.asphttp://www.alz.org/dementia/vascular-dementia-symptoms.asp


20/43

Answer: (D)The client is experiencing visual hallucination

Rationale: The presence of a sensory stimulus correlates with the definition of ahallucination, which is a false sensory perception.

Distractor: (B) The client is experiencing dysarthria

Rationale:Aphasia refers to a communication problem. Dysarthria is difficulty inspeech production. Flight of ideas is rapid shifting from one topic to another.

Source:http://www.healthline.com/health/hallucinationshttp://en.wikipedia.org/wiki/Dysarthria

46. Jessica is admitted to the psychiatric clinic for treatment of anorexia nervosa.To promote the clients physical health, the nurse should plan to:

Stem:Anorexia nervosaAnswer: (C)Monitor vital signs, serum electrolyte levels, and acid-base balance.

Rationale: An anorexic client who requires hospitalization is in poor physicalcondition from starvation and may die as a result of arrhythmias, hypothermia,malnutrition, infection, or cardiac abnormalities secondary to electrolyteimbalances. Therefore, monitoring the clients vital signs, serum electrolyte level,and acid base balance is crucial.

Distractor: (D) Instruct the client to keep an accurate record of food and fluid intake.

Rationale: Option A may worsen anxiety. Option B is incorrect because a weightobtained after breakfast is more accurate than one obtained after the eveningmeal. Option D would reward the client with attention for not eating and reinforcethe control issues that are central to the underlying psychological problem; also,the client may record food and fluid intake inaccurately.

Source:http://en.wikipedia.org/wiki/Anorexia_nervosa

47. Jessica is a psychiatric client is to be discharged with orders for haloperidol(haldol) therapy. When developing a teaching plan for discharge, the nurseshould include cautioning the client against:

Stem: Haloperidol therapyAnswer: (B)Staying in the sun

Rationale: Haldol causes photosensitivity. Severe sunburn can occuron exposure to the sun.


21/43

Distractor: (C) Ingesting wine and cheese

Rationale: Option C is contraindicated for patients taking MAOIs.

Source:http://en.wikipedia.org/wiki/Haloperidol

48. Which medications have been found to help reduce or eliminate panicattacks?

Stem: Panic attackAnswer: (A)Antidepressants

Rationale: Tricyclic and monoamine oxidase (MAO) inhibitor antidepressantshave been found to be effective in treating clients with panic attacks. Why these

drugs help control panic attacks isnt clearlyunderstood.

Distractor: (C)Antipsychotics

Rationale: Anticholinergic agents, which are smooth-muscle relaxants, relievephysical symptoms of anxiety but dont relieve the anxiety itself. Antipsychoticdrugs are inappropriate because clients who experience panic attacks arentpsychotic. Mood stabilizers arent indicated because panic attacks are rarelyassociated with mood changes.

Source:http://en.wikipedia.org/wiki/Monoamine_oxidase_inhibitorhttp://en.wikipedia.org/wiki/Antipsychotic

49. Ensuring that there is an informed consent on the part of the patient before asurgery is done, illustrates the bioethical principle of:

Stem: Bioethical PrincipleAnswer: (B)Autonomy

Rationale: Informed consent means that the patient fully understands about thesurgery, including the risks involved and the alternative solutions. In givingconsent it is done with full knowledge and is given freely. The action of allowingthe patient to decide whether a surgery is to be done or not exemplifies thebioethical principle of autonomy.

Distractor: (D) Non-maleficence

Rationale: Non-maleficence mean do no harm. We must refrain from providingineffective treatments or acting with malice toward patients.
http://en.wikipedia.org/wiki/Antipsychotichttp://en.wikipedia.org/wiki/Antipsychotic


22/43

Source:http://missinglink.ucsf.edu/lm/ethics/content%20pages/fast_fact_bene_nonmal.htm

50. The outcome that is unrelated to a crisis state is:

Stem: Crisis stateAnswer: (D)A higher level of anxiety continuing for more than 3 months.

Rationale: This is not an expected outcome of a crisis because by definition acrisis would be resolved in 6 weeks.

Distractor: (A) Learning more constructive coping skills

Rationale: Learning more constructive coping skills is an outcome most relatedto crisis state.

51. Jessica with chronic schizophrenia takes neuroleptic medication is admittedto the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension,and diaphoresis. These findings suggest which life-threatening reaction:

Stem: Chronic SchizophreniaAnswer: (C)Neuroleptic malignant syndrome.

Rationale: The clients signs and symptoms suggest neurolepticmalignantsyndrome, a life-threatening reaction to neuroleptic medication that requiresimmediate treatment.

Distractor: (D)Akathisia

Rationale: Tardive dyskinesia causes involuntary movements of the tongue,mouth, facial muscles, and arm and leg muscles. Dystonia is characterized bycramps and rigidity of the tongue, face, neck, and back muscles. Akathisiacauses restlessness, anxiety, and jitteriness.

Source:http://en.wikipedia.org/wiki/Akathisia

52. Nurse Angela ensures a therapeutic environment for all the client. Which ofthe following best describes a therapeutic milieu?

Stem: Therapeutic MilieuAnswer: (C)A living, learning or working environment.


23/43

Rationale: A therapeutic milieu refers to a broad conceptual approach in whichall aspects of the environment are channeled to provide a therapeuticenvironment for the client. The six environmental elements include structure,safety, norms; limit setting, balance and unit modification.

Distractor: (D)A permissive and congenial environment

Rationale: A. Behavioral approach in psychiatric care is based on the premisethat behavior can be learned or unlearned through the use of reward andpunishment. B. Cognitive approach to change behavior is done by correctingdistorted perceptions and irrational beliefs to correct maladaptive behaviors. D.This is not congruent with therapeutic milieu.

Source:http://en.wikipedia.org/wiki/Milieu_therapy

53. Jessica, an adolescent who is depressed and reported by his parents ashaving difficulty in school is brought to the community mental health center to beevaluated. Which of the following other health problems would the nursesuspect?

Stem: DepressionAnswer: (B)Behavioral difficulties

Rationale: Adolescents tend to demonstrate severe irritability and behavioralproblems rather than simply a depressed mood.

Distractor: (D) Labile mood

Rationale: Anxiety disorder is more commonly associated with small childrenrather than with adolescents. Cognitive impairment is typically associated withdelirium or dementia. Labile mood is more characteristic of a client withcognitive impairment or bipolar disorder.

Source:http://en.wikipedia.org/wiki/Anxiety_disorderhttp://psychcentral.com/encyclopedia/2008/labile-mood/

54. Nurse Angela knows that the non-antipsychotic medication used to treatsome clients with schizoaffective disorder is:

Stem: Non-antipsychotic medication for schizoaffective disorderAnswer: (C)lithium carbonate (Lithane)

Rationale: Lithium carbonate, an antimania drug, is used to treat clients withschizoaffective disorder, a psychotic disorder once classified under
http://en.wikipedia.org/wiki/Anxiety_disorderhttp://en.wikipedia.org/wiki/Anxiety_disorder


24/43

schizophrenia that causes affective symptoms, including manic-like activity.Lithium helps control the affective component of this disorder

Distractor: (B) Chlordiazepoxide (Librium)

Rationale: Phenelzine is a monoamine oxidase inhibitor prescribed for clientswho dont respond to other antidepressant drugs such asimipramine. Chlordiazepoxide, an antianxiety agent, generally is contraindicatedin psychotic clients. Imipramine, primarily considered an antidepressant agent, isalso used to treat clients with agoraphobia and that undergoing cocainedetoxification.

Source:http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682078.html

55. Nurse Angela recognizes that the suicidal risk for depressed client is greatest:

Stem: Suicidal risk for depressed clientAnswer: (A)As their depression begins to improve

Rationale:At this point the client may have enough energy to plan and executean attempt.

Distractor: (D)As they lose interest in the environment

Rationale: As the client loses interest in his/her environment, that means hedoesnt yet have the energy and will to attempt to kill themselves.

56. Jessica, 17 years old was sexually attacked while on her way home fromschool. She is brought to the hospital by her mother. Rape is an example ofwhich type of crisis:Stem: RapeAnswer: (B)Adventitious

Rationale:Adventitious crisis is a crisis involving a traumatic event. It is not partof everyday life.

Distractor: (A) Situational

Rationale: A. Situational crisis is from an external source that upset onespsychological equilibrium C and D. Are the same. They are transitional ordevelopmental periods in life

Source:http://medical-dictionary.thefreedictionary.com/adventitious+crisishttp://www.uh.edu/crc/sit.html


25/43

57. Nurse Angela is aware that Ritalin is the drug of choice for a child with ADHD.The side effects of the following may be noted by the nurse:

Stem: Sides effects of Ritalin

Answer: (A)increased attention span and concentration

Rationale: The medication has a paradoxic effect that decreases hyperactivityand impulsivity among children with ADHD.

Distractor: (B) Increase in appetite

Rationale: Side effects of Ritalin include anorexia, insomnia, diarrhea andirritability.

Source:

http://www.drugs.com/ritalin.html

58. Ms. Gonzales visits the physicians office to seek treatment for depression,feelings of hopelessness, poor appetite, insomnia, fatigue, low self-esteem, poorconcentration, and difficulty making decisions. The client states that thesesymptoms began at least 2 years ago. Based on this report, the nurse Angelasuspects:

Stem: Long term depressionAnswer: (D)Dysthymic disorder.

Rationale: Dysthymic disorder is marked by feelings of depression lasting atleast 2 years, accompanied by at least two of the following symptoms: sleepdisturbance, appetite disturbance, low energy or fatigue, low self-esteem, poorconcentration, difficulty making decisions, and hopelessness. These symptomsmay be relatively continuous or separated by intervening periods of normal moodthat last a few days to a few weeks.

Distractor: (B)Atypical affective disorder

Rationale: Cyclothymic disorder is a chronic mood disturbance of at least 2years duration marked by numerous periods of depression andhypomania.

Atypical affective disorder is characterized by manic signs and symptoms and isopposite of the symptoms Ms. Gonzales reported. Major depression is arecurring, persistent sadness or loss of interest or pleasure in almost all activities,with signs and symptoms recurring for at least 2 weeks.

Source:http://www.mentalhealth.com/dis/p20-md04.htmlhttp://www.mayoclinic.com/health/cyclothymia/DS00729


26/43

59. Nurse Angela is aware that most crisis situations should resolve in about:

Stem: Crisis situation durationAnswer: (B)4 to 6 weeks

Rationale: Crisis is self-limiting and lasts from 4 to 6 weeks.

Distractor: (D) 6 to 12 months

Rationale:A crisis lasting up to 6 to 12 months is equivalent to major depression

60. The nurse is aware that the side effect of electroconvulsive therapy that aclient may experience:

Stem: Side effects of Electroconvulsive Therapy

Answer: (C)Confusion for a time after treatment

Rationale: The electrical energy passing through the cerebral cortex during ECTresults in a temporary state of confusion after treatment.

Distractor: (D) Complete loss of memory for a time

Rationale: The client who has undergone ECT will not suffer from a completeloss of memory for a time.

61. John is admitted for detoxification after a cocaine overdose. The client tellsthe nurse that he frequently uses cocaine but that he can control his use if hechooses. Which coping mechanism is he using?

Stem: Defense mechanismAnswer: (D)Denial

Rationale: Denial is unconscious defense mechanism in whichemotional conflict and anxiety is avoided by refusing to acknowledgefeelings, desires, impulses, or external facts that are consciously intolerable.

Distractor: (B) Logical thinking

Rationale: Withdrawal is a common response to stress, characterized byapathy. Logical thinking is the ability to think rationally and makeresponsible decisions, which would lead the client admitting the problem andseeking help. Repression is suppressing past events from theconsciousness because of guilty association.

Source:


27/43

http://www.ask.com/question/what-is-logical-thinkinghttp://en.wikipedia.org/wiki/Denial

62. The nurse is caring for a client diagnosed with antisocial personality disorder.The client has a history of fighting, cruelty to animals, and stealing. Which of the

following traits would the nurse be most likely to uncover during assessment?

Stem:Antisocial personality disorderAnswer: (D)A low tolerance for frustration

Rationale: Clients with an antisocial personality disorder exhibit a low tolerancefor frustration, emotional immaturity, and a lack of impulse control.

Distractor: (C) Demonstrates ability to maintain close, stable relationships

Rationale: They commonly have a history of unemployment, miss

work repeatedly, and quit work without other plans for employment. Theydontfeel guilt about their behavior and commonly perceive themselvesas victims. They also display a lack of responsibility for the outcome oftheir actions. Because of a lack of trust in others, clients withantisocial personality disorder commonly have difficulty developing stable,close relationships.

Source:http://psychcentral.com/disorders/antisocial-personality-disorder-symptoms/

63. A 65 years old client is in the first stage of Alzheimers disease. Nurse Angelashould plan to focus this clients care on:

Stem: First stage of Alzheimers diseaseAnswer: (B)Providing emotional support and individual counseling.

Rationale: Clients in the first stage of Alzheimers disease are awarethat something is happening to them and may become overwhelmedand frightened. Therefore, nursing care typically focuses on providing emotionalsupport and individual counseling.

Distractor: (A) Offering nourishing finger foods to help maintain the clients nutritionalstatus

Rationale: The other options are appropriate during the second stage ofAlzheimers disease, when the client needs continuous monitoring to preventminor illnesses from progressing into major problems and when maintainingadequate nutrition may become a challenge. During this stage, offeringnourishing finger foods helps clients to feed themselves and maintain adequatenutrition.


28/43

Source:http://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp?gclid=CP6EzLnytLsCFcZV4god_w4A9A

64. Hermione, a 42-year-old client with a diagnosis of chronic undifferentiatedschizophrenia lives in a rooming house that has a weekly nursing clinic. Shescratches while she tells the nurse she feels creatures eating away at her skin.Which of the following interventions should be done first?

Stem: Chronic Undifferentiated SchizophreniaAnswer: (C)Assess for possible physical problems such as rash

Rationale: Clients with schizophrenia generally have poor visceral recognitionbecause they live so fully in their fantasy world. They need to have as in-depthassessment of physical complaints that may spill over into their delusional

symptoms.

Distractor: (A) Talk about her hallucinations and fears

Rationale: Talking with the client wont provide asassessment of his itching, anditching isnt as adverse reaction of antipsychotic drugs, calling the physician toget the clients medication increased doesnt address his physical complaints.

Source:http://www.helpguide.org/mental/schizophrenia_symptom.htm

65. When Nurse Angela is providing care to her patient, she must remember thather duty is bound to not do any action that will cause the patient harm. This is themeaning of the bioethical principle:

Stem: Principle of BioethicsAnswer: (A) Non-maleficence

Rationale: Non-maleficence means do not cause harm or do any action that willcause any harm to the patient/client. To do good is referred as beneficence.

Distractor: (D) Solidarity

Rationale: Solidarity is unity that produces or is based on community ofinterests, objectives, and standards.

Source:http://en.wikipedia.org/wiki/Solidarity


29/43


30/43

68. Nurse Angela is monitoring a male client who has been placed in restraintsbecause of violent behavior. Nurse determines that it will be safe to remove therestraints when:

Stem: Restraints

Answer: (C)No acts of aggression have been observed within 1 hour after the releaseof two of the extremity restraints.

Rationale: The best indicator that the behavior is controlled, if the client exhibitsno signs of aggression after partial release of restraints.

Distractor: (B) The client apologizes and tells the nurse that it will never happen again

Rationale: Options A, B, and D do not ensure that the client has controlled thebehavior.

69. Jessica is experiencing hallucinations tells the nurse, The voices are tellingme Im no good. The client asks if the nurse hears the voices. The mostappropriate response by the nurse would be:

Stem: HallucinationAnswer: (B)No, I do not hear your voices, but I believe you can hearthem.

Rationale: The nurse, demonstrating knowledge and understanding, accepts theclients perceptions even though they are hallucinatory.

Distractor: (A) It is the voice of your conscience, which only you can control.

Rationale: Saying this as a response to the clients statement will not help herbecause the nurse it not presenting reality.

70. Freud stresses out that EGO is:

Stem: Definition of Ego.Answer: (A) Distinguishes between things in the mind and things in the reality.

Rationale: The ego is responsible for distinguishing what is real and what is not.It is the one that balances the Id and Superego.

Distractor: (B) Moral arm of the personality that strives for perfection than pleasure

Rationale: Options B and D are a characteristic of the super ego which is thecontroller of instincts and drives and serves as the conscience of moral arm. TheId is our drive and instinct that is mediated by the ego and controlled by the superego.


31/43

Source:http://en.wikipedia.org/wiki/Id,_ego_and_super-ego

71. Nurse Angela is developing a plan of care for a client with anorexia nervosa.Which action should the nurse include in the plan?

Stem:Anorexia NervosaAnswer: (C)Set up a strict eating plan for the client.

Rationale: Establishing a consistent eating plan and monitoring the clientsweight are very important in this disorder.

Distractor: (B) Provide privacy during meals

Rationale: The family and friends should be included in the clients care. Theclient should be monitored during meals-not given privacy. Exercise must be

limited and supervised.

72. Jessica is to be discharged on a regimen of lithium carbonate. In the teachingplan for discharge the nurse should include:

Stem: Lithium CarbonateAnswer: (D)Encouraging the client to have blood levels checked as ordered.

Rationale: Blood levels must be checked monthly or bimonthly when the client ison maintenance therapy because there is only a small range betweentherapeutic and toxic levels.

Distractor: (A)Advising the client to watch the diet carefully

Rationale: The client ca maintain a normal diet with an average consumption ofSodium

Source:http://www.rxlist.com/eskalith-drug/consumer-missed-dose.htm

73. Which information is most important for the nurse Angela to include in ateaching plan for a male schizophrenic client taking clozapine (Clozaril)?

Stem: Male schizophrenic client taking clozapineAnswer: (B)Report a sore throat or fever to the physician immediately.

Rationale: A sore throat and fever are indications of an infection caused byagranulocytosis, a potentially life-threatening complication of clozapine.

Distractor: (D) Stop the medication when symptoms have subside
http://www.rxlist.com/eskalith-drug/consumer-missed-dose.htmhttp://www.rxlist.com/eskalith-drug/consumer-missed-dose.htm


32/43

Rationale: Because of the risk of agranulocytosis, white blood cell (WBC) countsare necessary weekly, not monthly. If the WBC count drops below 3,000/l, themedication must be stopped. Hypotension may occur in clients taking thismedication. Warn the client to stand up slowly to avoid dizziness from orthostatic

hypotension. The medication should be continued, even when symptoms havebeen controlled. If the medication must be stopped, it should be slowly taperedover 1 to 2 weeks and only under the supervision of a physician.

Source:http://en.wikipedia.org/wiki/Clozapine

74. Jessica has a lithium level of 2.4 mEq/L. The nurse immediately would assessthe client for which of the following signs or symptoms?

Stem: Lithium level

Answer: (C)Blurred vision

Rationale:At lithium levels of 2 to 2.5 mEq/L the client will experienced blurred ,muscle twitching, severe hypotension, and persistent nausea and vomiting

Distractor: (D) Fecal incontinence

Rationale: With levels between 1.5 and 2 mEq/L the client experiencingvomiting, diarrhea, muscle weakness, ataxia, dizziness, slurred speech, andconfusion. At lithium levels of 2.5 to 3 mEq/L or higher, urinary and fecalincontinence occurs, as well as seizures, cardiac dysrythmias, peripheralvascular collapse, and death.

75. Tristan is on Lithium has suffered from diarrhea and vomiting. What shouldthe nurse in-charge do first:

Stem: Diarrhea and vomitingAnswer: (D) Hold the next dose and obtain an order for a stat serum lithium level

Rationale: Diarrhea and vomiting are manifestations of Lithium toxicity. The nextdose of lithium should be withheld and test is done to validate the observation.

Distractor: (A) Recognize this as a drug interaction

Rationale:A. The manifestations are not due to drug interaction. B. Cogentin isused to manage the extra pyramidal symptom side effects of antipsychotics. C.The common side effects of Lithium are fine hand tremors, nausea, polyuria andpolydipsia.

Source:


33/43

http://www.nlm.nih.gov/medlineplus/ency/article/002667.htm

76. Jessica, with a diagnosis of generalized anxiety disorder wants to stop takinghis lorazepam (Ativan). Which of the following important facts should nurseAngela discuss with the client about discontinuing the medication?

Stem: Discontinuing Lorazepam (Ativan)Answer: (D) Stopping the drug can cause withdrawal symptoms

Rationale: Stopping antianxiety drugs such as benzodiazepines can cause thepatient to have withdrawal symptoms.

Distractor: (B) Stopping the drug increases cognitive abilities

Rationale: Stopping a benzodiazepine doesnt tend to cause depression,increase cognitive abilities, or decrease sleeping difficulties.

Source:http://www.rxlist.com/ativan-drug.htm

77. Which of the following descriptions of a clients experience and behavior canbe assessed as an illusion?

Stem: IllusionAnswer: (D)The client looks at the shadow on a wall and tells the nurse she seesfrightening faces on the wall.

Rationale: Minor memory problems are distinguished from dementia by theirminor severity and their lack of significant interference with the clients social oroccupational lifestyle.

Distractor: (C) The client becomes anxious whenever the nurse leaves the bedside

Rationale: Option C is a manifestation of paranoia.

Source:http://en.wikipedia.org/wiki/Paranoid_personality_disorder

78. Jun approaches the nurse and tells that he hears a voice telling him that hesevil and deserves to die. Which of the following terms describes the clientsperception?

Stem: False perceptionAnswer: (C)Hallucination


34/43

Rationale: Hallucinations are sensory experiences that are misrepresentationsof reality or have no basis in reality.

Distractor: (D) Idea of Reference

Rationale: Delusions are beliefs not based in reality. Disorganized speech ischaracterized by jumping from one topic to the next or using unrelated words. Anidea of reference is a belief that an unrelated situation holds special meaningfor the client.

Source:http://en.wikipedia.org/wiki/Ideas_of_reference_and_delusions_of_reference

79. Mike is admitted to a psychiatric unit with a diagnosis of undifferentiatedschizophrenia. Which of the following defense mechanisms is probably used bymike?

Stem: Defense MechanismAnswer: (C) Regression

Rationale: Regression, a return to earlier behavior to reduce anxiety, is the basicdefense mechanism in schizophrenia.

Distractor: (B) Rationalization

Rationale: Projection is a defense mechanism in which one blames others andattempts to justify actions; itsused primarily by people with paranoidschizophrenia and delusional disorder. Rationalization is a defense mechanismused to justify ones action. Repression is the basic defense mechanism in theneuroses; itsan involuntary exclusion of painful thoughts, feelings, orexperiences from awareness.

Source:http://en.wikipedia.org/wiki/Regressionhttp://en.wikipedia.org/wiki/Rationalization_(making_excuses)

80. The nurse is aware that the following ways in vascular dementia different fromAlzheimers disease is:

Stem: Difference between Vascular Dementia and Alzheimers diseaseAnswer: (A) Vascular dementia has more abrupt onset

Rationale: Vascular dementia differs from Alzheimers disease in that ithas amore abrupt onset and runs a highly variable course.

Distractor: (D) The inability to perform motor activities occurs in vascular dementia


35/43


36/43

Answer: (B) Paranoid thoughts

Rationale: Clients with schizotypal personality disorder experience excessivesocial anxiety that can lead to paranoid thoughts.

Distractor: (C) Emotional affect

Rationale: Aggressive behavior is uncommon, although these clients mayexperience agitation with anxiety. Their behavior is emotionally cold with aflattened affect, regardless of the situation. These clients demonstrate a reducedcapacity for close or dependent relationships.

Source:http://en.wikipedia.org/wiki/Schizotypal_personality_disorder

84. When establishing an initial nurse-client relationship, Nurse Angela should

explore with the client the:

Stem: Nurse-client RelationshipAnswer: (A)Clients perception of the presenting problem.

Rationale: The nurse can be most therapeutic by starting where the client is,because it is the clients concept of the problem that serves as thestarting pointof the relationship.

Distractor: (B) Occurrence of fantasies the client may experience

Rationale: Choices B, C, and D are established once the nurse was able to buildrapport between her and the client.

Source:http://en.wikipedia.org/wiki/Nurse%E2%80%93client_relationship

85. Nurse Angela is caring for a client who has been diagnosed with delirium.Which statement about delirium is true?

Stem: DeliriumAnswer: (D) Its characterized by an acute onset and lasts hours to a number of days

Rationale: Delirium has an acute onset and typically can last from several hoursto several days

Distractor: (C) Its characterized by a slowly evolving onset and lasts about 1 month

Rationale: Delirium has an acute onset and typically can last from several hoursto several days


37/43

Source:http://www.mayoclinic.com/health/delirium/DS01064/DSECTION=symptoms

86. Jessica with a history of polysubstance abuse is admitted to the facility. She

complains of nausea and vomiting 24 hours after admission. The nurse assessesthe client and notes piloerection, pupillary dilation, and lacrimation. The nursesuspects that the client is going through which of the following withdrawals?

Stem: Type of WithdrawalAnswer: (D) Opioid withdrawal

Rationale: The symptoms listed are specific to opioid withdrawal.

Distractor: (B) Cannabis withdrawal

Rationale: Alcohol withdrawal would show elevated vital signs. There is no realwithdrawal from cannabis. Symptoms of cocaine withdrawal includedepression, anxiety, and agitation.

Source:https://www.marijuana-anonymous.org/literature/pamphlets/detoxing-from-marijuana

87. Nurse Angela is aware that the following pharmacologic agents are sedativehypnotic medication is used to induce sleep for a client experiencing a sleepdisorder is:

Stem: Sedative hypnotic agent for a sleep disorderAnswer: (A)Triazolam (Halcion)

Rationale: Triazolam is one of a group of sedative hypnotic medication that canbe used for a limited time because of the risk of dependence.

Distractor: (D) Risperidone (Risperdal)

Rationale: Paroxetine is a scrotonin-specific reutake inhibitor used for treatmentof depression panic disorder, and obsessive-compulsive disorder. Fluoxetine is ascrotonin-specific reuptake inhibitor used for depressive disordersand obsessive-compulsive disorders. Risperidome is indicated forpsychotic disorders.



38/43

88.During conversation of Nurse Angela with a client, he observes that the clientshift from one topic to the next on a regular basis. Which of the following termsdescribes this disorder?

Stem: Disorder

Answer: (D)Loose association

Rationale: Loose associations are conversations that constantly shift in topic.

Distractor: (B) Concrete thinking

Rationale: Concrete thinking implies highly definitive thought processes. Flight ofideas is characterized by conversation thats disorganized from theonset. Looseassociations dont necessarily start in a cogently, thenbecomes loose.

Source:

http://medical-dictionary.thefreedictionary.com/concrete+thinking

89. The therapeutic approach in the care of Coco, an autistic child includes thefollowing EXCEPT:

Stem: Therapeutic approach in an autistic childAnswer: (D)Rearrange the environment to activate the child

Rationale: The child with autistic disorder does not want change. Maintaining aconsistent environment is therapeutic.

Distractor: (C) Provides safety measures

Rationale: A. Angry outburst can be re-channeling through safe activities. B.Acceptance enhances a trusting relationship. C. Ensure safety from self-destructive behaviors like head banging and hair pulling.

90. Jessica, a 9 year old child has very limited vocabulary and interaction skills.She has an I.Q. of 45. She is diagnosed to have Mental retardation of thisclassification:

Stem: Mental retardationAnswer: (C)Moderate

Rationale: The child with moderate mental retardation has an I.Q. of 35- 50

Distractor: (D) Severe

Rationale: Profound Mental retardation has an I.Q. of below 20; Mildmental retardation 50-70 and severe mental retardation has an I.Q. of 20-35.


39/43

Source:http://behavenet.com/node/21026

91. Angela with a diagnosis of depression is started on imipramine (Tofranil), 75

mg by mouth at bedtime. The nurse should tell the client that:

Stem: ImipramineAnswer: (D)This medication may initially cause tiredness, which should become lessbothersome over time.

Rationale: Sedation is a common early adverse effect of imipramine, a tricyclicantidepressant, and usually decreases as tolerance develops.

Distractor: (C) The client should avoid eating such foods as aged cheeses. Yogurt, andchicken livers while taking medication

Rationale: Dietary restrictions, such as avoiding aged cheeses, yogurt, andchicken livers, are necessary for a client taking a monoamine oxidase inhibitor,not a tricyclic antidepressant.

Source:http://www.mayoclinic.com/health/maois/MH00072

92. Which nursing intervention would be most appropriate if a male client developorthostatic hypotension while taking amitriptyline (Elavil)?

Stem: Orthostatic HypotensionAnswer: (B)Advising the client to sit up for 1 minute before getting out of bed.

Rationale: To minimize the effects of amitriptyline-inducedorthostatic hypotension, the nurse should advise the client to sit up for 1minute before getting out of bed. Orthostatic hypotension commonly occurswith tricyclic antidepressant therapy. In these cases, the dosage may be reducedor the physician may prescribe nortriptyline, another tricyclic antidepressant.

Distractor: (C) Instructing the client to double the dosage until the problem resolves.

Rationale: Orthostatic hypotension disappears only when the drugis discontinued.

Source:http://www.medicinenet.com/orthostatic_hypotension/page2.htm

93. Nurse Angela recognizes that the most important factor necessary for theestablishment of trust in a critical care area is:


40/43

Stem: Establishment of TrustAnswer: (D)Presence

Rationale: The constant presence of a nurse provides emotional

support because the client knows that someone is attentive and available incase of an emergency.

Distractor: (B) Respect

Rationale: Respect can only be gained after the nurse has established trust withthe client.

94. When assessing the premorbid personality characteristics of a client with amajor depression, it would be unusual for the nurse to find that this clientdemonstrated:

Stem: Characteristics of a major depressionAnswer: (C)Diverse interest

Rationale: Before onset of depression, these clients usually have very narrow,limited interest.

Distractor: (D) Over meticulousness

Rationale: A client suffering from major depression does not have any intereston the surrounding environment.

Source:http://www.mayoclinic.com/health/depression/DS00175/DSECTION=symptoms

95. Rose with paranoid schizophrenia repeatedly uses profanity during an activitytherapy session. Which response by the nurse would be most appropriate?

Stem: Paranoid SchizophreniaAnswer: (C)Your cursing is interrupting the activity. Take time out in yourroom for 10minutes.

Rationale: The nurse should set limits on client behavior to ensure a comfortablefor all clients.

Distractor: (B) Youre just doing this to get back at me for making you come to therapy.

Rationale: The nurse should accept hostile or quarrelsome client outburstswithin limits without becoming personally offended, as in option A. Option B isincorrect because it implies that the clients actions reflect feelings toward the


41/43

staff instead of the clients ownmisery. Judgmental remarks, such as option D,may decrease the clientsself-esteem.

96. After taking an overdose of phenobarbital (Barbita), Jessica is admitted to theemergency department. Dr. Aviles prescribes activated charcoal (Charcocaps) to

be administered by mouth immediately. Before administering the dose, the nurseverifies the dosage ordered. What is the usual minimum dose of activatedcharcoal?

Stem: Minimum dose of activated charcoalAnswer: (C)30 g mixed in 250 ml of water

Rationale: The usual adult dosage of activated charcoal is 5 to 10 times theestimated weight of the drug or chemical ingested, or a minimum dose of 30 g,mixed in 250 ml of water.

Distractor: (A) 5 g mixed in 250 ml of water

Rationale: Doses less than this will be ineffective; doses greater than this canincrease the risk of adverse reactions, although toxicity doesnt occur withactivated charcoal, even at the maximum dose.

Source:http://en.wikipedia.org/wiki/Activated_carbon

97. Lily, a newly admitted client was diagnosed with delirium and has history ofhypertension and anxiety. She had been taking digoxin, furosemide (Lasix), anddiazepam (Valium) for anxiety. This clients impairment may be related to which ofthe following conditions?

Stem: DeliriumAnswer: (C)Drug intoxication

Rationale: This client was taking several medications that have a propensity fordelirium; digoxin (a digitalis glycoxide), furosemide (a thiazide diuretic), anddiazepam (a benzodiazepine). Sufficient supporting data dont exist to suspectthe other options as causes.

Distractor: (B) Metabolic acidosis

Rationale: Metabolic acidosis can manifest through confusion or lethargy but itdoes not cause delirium

Source:http://www.nlm.nih.gov/medlineplus/ency/article/000335.htm


42/43

98. Klaus, an outpatient in psychiatric facility is diagnosed with dysthymicdisorder. Which of the following statement about dysthymic disorder is true?

Stem: Dysthymic DisorderAnswer: (D)Its a mood disorder similar to major depression but of mild tomoderate

severity

Rationale: Dysthymic disorder is a mood disorder similar to major depressionbut it remains mild to moderate in severity.

Distractor: (C) Its a form of depression that occurs in the fall and winter

Rationale: Cyclothymic disorder is a mood disorder characterized by a moodrange from moderate depression to hypomania. Bipolar I disorder ischaracterized by a single manic episode with no past major depressive episodes.Seasonal affective disorder is a form of depression occurring in the fall and

winter.

Source:http://emedicine.medscape.com/article/290686-overview

99. Which of the following interventions is important for a patient experiencingparanoid personality disorder taking olanzapine (Zyprexa)?

Stem: Paranoid personality disorder taking Olanzapine (Zyprexa)Answer: (C)Explain that the drug is less affective if the client smokes

Rationale: Olanzapine (Zyprexa) is less effective for clients whosmoke cigarettes.

Distractor: (B) Teach the client to watch for extrapyramidal adverse reaction

Rationale: Serotonin syndrome occurs with clients who take a combination ofantidepressant medications. Olanzapine doesnt causeeuphoria, andextrapyramidal adverse reactions arent a problem.However, the client should beaware of adverse effects such as tardive dyskinesia.


100. Francis tells the nurse that her coworkers are sabotaging the computer.When the nurse asks questions, the client becomes argumentative. This behaviorshows personality traits associated with which of the following personalitydisorder?

Stem: Type of Personality Disorder


43/43

Answer: (C)Paranoid

Rationale: Because of their suspiciousness, paranoid personalities ascribemalevolent activities to others and tent to be defensive, becoming quarrelsomeand argumentative.

Distractor: (D) Schizotypal

Rationale: Clients with antisocial personality disorder can also be antagonisticand argumentative but are less suspicious than paranoid personalities. Clientswith histrionic personality disorder are dramatic, not suspicious andargumentative. Clients with schizoid personality disorder are usually detachedfrom other and tend to have eccentric behavior.

Source:http://en.wikipedia.org/wiki/Personality_disorder