EXAM 2

Question 1

1. Before a victim of sexual assault is discharged from the emergency department, the nurse should:
   a. notify the victim’s family to provide emotional support.
   b. offer to stay with the patient until stability is regained.
   c. advise the patient to try not to think about the assault.
   d. provide referral information verbally and in writing.

Answer 1

ANS: D

Question 2

A rape victim tells the emergency nurse, “I feel so dirty. Help me take a shower before I get

examined. ” The nurse should: (select all that apply)
a. arrange for the victim to shower.
b. explain that bathing destroys evidence.
c. give the victim a basin of water and towels.
d. offer the victim a shower after evidence is collected.
e. explain that bathing facilities are not available in the emergency department.

Answer 2

ANS: B, D

Question 3

3. After treatment for a detached retina, a survivor of intimate partner abuse says, “My partner only abuses me when I make mistakes. I’ve considered leaving, but I was brought up to believe you stay together, no matter what happens.” Which diagnosis should be the focus of the nurse’s initial actions?
   a. Risk for injury related to physical abuse from partner
   b. Social isolation related to lack of a community support system
   c. Ineffective coping related to uneven distribution of power within a relationship
   d. Deficient knowledge related to resources for escape from an abusive relationship

Answer 3

ANS: A

Question 4

5. A 10-year-old cares for siblings while the parents work because the family cannot afford a babysitter. This child says, “My father doesn’t like me. He calls me stupid all the time.” The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources as priorities to stabilize the home situation? Select all that apply.

a. Parental sessions to teach childrearing practices
b. Anger management counseling for the father
c. Continuing home visits to give support
d. A safety plan for the wife and children
e. Placing the children in foster care

Answer 4

ANS: A, B, C

Question 5

6. A community health nurse visits a family with four children. The father behaves angrily, finds fault with the oldest child, and asks twice, “Why are you such a stupid kid?” The wife says, “I have difficulty disciplining the children. It’s so frustrating.” Which comments by the nurse will facilitate an interview with these parents? Select all that apply.
   a. “Tell me how you discipline your children.”
   b. “How do you stop your baby from crying?”
   c. “Caring for four small children must be difficult.”
   d. “Do you or your husband ever spank your children?”
   e. “Calling children ‘stupid’ injures their self-esteem.”

Answer 5

ANS: A, B, C

Question 6

7. A depressed patient says, “Nothing matters anymore.” What is the most appropriate response by the nurse?
   a. “Are you having thoughts of suicide?”
   b. “I am not sure I understand what you are trying to say.”
   c. “Try to stay hopeful. Things have a way of working out.”
   d. “Tell me more about what interested you before you became depressed.”

Answer 6

ANS: A

Question 7

8. Which individual in the emergency department should be considered at highest risk for completing suicide?
   An adolescent Asian American girl with superior athletic and academic skills who has
   a. asthma
   A 38-year-old single, African American female church member with fibrocystic breast
   b. disease
   c. A 60-year-old married Hispanic man with twelve grandchildren who has type 2 diabetes
   d. A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate

Answer 7

ANS: D

Question 8

9. A patient with fears of serious heart disease was referred to the mental health center by a cardiologist. Extensive diagnostic evaluation showed no physical illness. The patient says, “My chest is tight, and my heart misses beats. I’m often absent from work. I don’t go out much because I need to rest.” Which health problem is most likely?
   a. Dysthymic disorder
   b. Somatic symptom disorder
   c. Antisocial personality disorder
   d. Illness anxiety disorder (hypochondriasis)

Answer 8

ANS: D

Question 9

should understand that patients have difficulty giving up the symptoms because the symptoms:

a. are generally chronic
b. have a physiological
c. can be voluntarily controlled.basis.
d. provide relief from health anxiety.

Answer 9

ANS: D

Question 10

11. A patient diagnosed with a somatic symptom disorder says, “My pain is from an undiagnosed injury. I can’t take care of myself. I need pain medicine six or seven times a day. I feel like a baby because my family has to help me so much.” It is important for the nurse to assess:
    a. mood. .
    b. cognitive style.
    c. secondary gains
    d. identity and memory.

Answer 10

ANS: C

Question 11

12. A patient diagnosed with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about:

a. restricting sodium intake to 1 gram daily.
b. minimizing exposure to bright sunlight.
c. reporting increased suicidal thoughts.
d. maintaining a tyramine-free diet.

Answer 11

ANS: C

Question 12

13. A nurse instructs a patient taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of:
    a. hypotensive shock.
    b. hypertensive crisis.
    c. cardiac dysrhythmia
    d. cardiogenic shock.

Answer 12

ANS: B

Question 13

14. A patient diagnosed with major depression shows vegetative signs of depression. Which
    nursing actions should be implemented? Select all that apply.
    a. Offer laxatives if needed.
    b. Monitor food and fluid intake.
    c. Provide a quiet sleep environment.
    d. Eliminate all daily caffeine intake.
    e. Restrict intake of processed foods.

Answer 13

ANS: A, B, C

Question 14

15. A student nurse caring for a patient diagnosed with depression reads in the patient’s medical record, “This patient shows vegetative signs of depression.” Which nursing diagnoses most clearly relate to the vegetative signs? Select all that apply.
    a. Imbalanced nutrition: less than body requirements
    b. Chronic low self-esteem
    c. Sexual dysfunction
    d. Self-care deficit
    e. Powerlessness
    f. Insomnia

Answer 14

ANS: A, C, D, F

Question 15

4. An adult has a history of physical violence against family when frustrated, followed by periods of remorse after each outburst. Which finding indicates a successful plan of care? The adult:
   a. expresses frustration verbally instead of physically.
   b. explains the rationale for behaviors to the victim.
   c. identifies three personal strengths.

d. agrees to seek counseling.

Answer 15

ANS: A

Question 16

16. The admission note indicates a patient diagnosed with major depression has anergia and anhedonia. For which measures should the nurse plan? Select all that apply.
    a. Channeling excessive energy
    b. Reducing guilty ruminations
    c. Instilling a sense of hopefulness
    d. Assisting with self-care activities
    e. Accommodating psychomotor retardation

Answer 16

ANS: C, D, E

Question 17

17. A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine (Zyprexa). What is the rationale for the addition of olanzapine to the medication regimen? It will:
    a. minimize the side effects of lithium.
    b. bring hyperactivity under rapid control.
    c. enhance the antimanic actions of lithium.
    d. be used for long-term control of hyperactivity.

Answer 17

ANS: B

Question 18

18. The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Which response should the nurse provide?
    a. “A high proportion of patients with bipolar disorders are found among creative writers.”
    “A higher rate of relatives with bipolar disorder is found among patients with bipolar
    b. disorder.”
    “Patients with bipolar disorder have higher rates of relatives who respond in an exaggerated
    c. way to daily stress.”
    “More individuals with bipolar disorder come from high socioeconomic and educational
    d. backgrounds.”

Answer 18

ANS: B

Question 19

19. When a hyperactive patient diagnosed with acute mania is hospitalized, what is the initial nursing intervention?
    a. Allow the patient to act out feelings.

b. Set limits on patient behavior as necessary.
c. Provide verbal instructions to the patient to remain calm.
d. Restrain the patient to reduce hyperactivity and aggression.

Answer 19

ANS: B

Question 20

20. At a unit meeting, the staff discusses decor for a special room for patients with acute mania. Which suggestion is appropriate?
    a. An extra-large window with a view of the street
    b. Neutral walls with pale, simple accessories
    c. Brightly colored walls and print drapes
    d. Deep colors for walls and upholstery

Answer 20

ANS: B

Question 21

21. A patient diagnosed with schizophrenia tells the nurse, “I eat skiller. Tend to end. Easter. It blows away. Get it?” Select the nurse’s best response.
    a. “Nothing you are saying is clear.”
    b. “Your thoughts are very disconnected.”
    c. “Try to organize your thoughts and then tell me again.”
    d. “I am having difficulty understanding what you are saying.”

Answer 21

ANS: D

Question 22

22. The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?
    a. Auditory hallucinations c. Poor personal hygiene
    b. Delusions of grandeur d. Psychomotor agitation

Answer 22

ANS: C

Question 23

23. A patient diagnosed with schizophrenia anxiously says, “I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror.” While listening, the nurse should:
    a. sit close to the patient.
    b. place an arm protectively around the patient’s shoulders.
    c. place a hand on the patient’s arm and exert light pressure.

d. maintain a normal social interaction distance from the patient.

Answer 23

ANS: D

Question 24

24. The nurse is developing a plan for psychoeducational sessions for several adults diagnosed with schizophrenia. Which goal is best for this group? Members will:
    a. gain insight into unconscious factors that contribute to their illness.
    b. explore situations that trigger hostility and anger.
    c. learn to manage delusional thinking.
    d. demonstrate improved social skills.

Answer 24

ANS: D

Question 25

25. A patient asks, “What are neurotransmitters? The doctor said mine are imbalanced.” Select the nurse’s best response. a. “How do you feel about having imbalanced neurotransmitters?” b. “Neurotransmitters protect us from harmful effects of free radicals.” c. “Neurotransmitters are substances we consume that influence memory and mood.” d. “Neurotransmitters are natural chemicals that pass messages between brain cells.”

Answer 25

ANS: D

Question 26

26. A patient’s history shows drinking 4 to 6 liters of fluid and eating more than 6,000 calories per day. Which part of the central nervous system is most likely dysfunctional for this patient? a. Amydala c. Hippocampus b. Parietal lobe d. Hypothalamus

Answer 26

ANS: D

Question 27

27. The nurse prepares to assess a patient diagnosed with major depression for disturbances in circadian rhythms. Which question should the nurse ask this patient? a. “Have you ever seen or heard things that others do not?” b. “What are your worst and best times of the day?” c. “How would you describe your thinking?” d. “Do you think your memory is failing?”

Answer 27

ANS: B

Question 28

28. The nurse administers a medication that potentiates the action of gamma-aminobutyric acid (GABA). Which effect would be expected? a. Reduced anxiety c. More organized thinking b. Improved memory d. Fewer sensory perceptual alterations

Answer 28

ANS: A

Question 29

29. A nurse would anticipate that treatment for a patient with memory difficulties might include medications designed to: a. inhibit gamma-aminobutyric acid (GABA). b. prevent destruction of acetylcholine. c. reduce serotonin metabolism. d. increase dopamine activity.

Answer 29

ANS: B

Question 30

30. The therapeutic action of neurotransmitter inhibitors that block reuptake cause: a. decreased concentration of the blocked neurotransmitter in the central nervous system. b. increased concentration of the blocked neurotransmitter in the synaptic gap. c. destruction of receptor sites specific to the blocked neurotransmitter. d. limbic system stimulation.

Answer 30

ANS: B

Question 31

31. A patient has fear as well as increased heart rate and blood pressure. The nurse suspects increased activity of which neurotransmitter? a. Gamma-aminobutyric acid (GABA) c. Acetylcholine b. Norepinephrine d. Histamine

Answer 31

ANS: B

Question 32

32. A patient has acute anxiety related to an automobile accident 2 hours ago. The nurse should teach the patient about medication from which group? a. Tricyclic antidepressants c. Antimanic drugs b. Antipsychotic drugs d. Benzodiazepines

Answer 32

ANS: D

Question 33

33. Which instruction has priority when teaching a patient about clozapine (Clozaril)? a. “Avoid unprotected sex.” b. “Report sore throat and fever immediately.” c. “Reduce foods high in polyunsaturated fats.” d. “Use over-the-counter preparations for rashes.”

Answer 33

ANS: B

Question 34

34. A nurse instructs a patient taking a drug that inhibits monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: a. cardiac dysrhythmia. c. hypertensive crisis. b. hypotensive shock. d. hypoglycemia.

Answer 34

ANS: C

Question 35

35. A nurse caring for a patient taking a selective serotonin reuptake inhibitor (SSRI) will develop outcome criteria related to: a. coherent thought processes. c. reduced levels of motor activity. b. improvement in depression. d. decreased extrapyramidal symptoms.

Answer 35

ANS: B

Question 36

36. By which mechanism do selective serotonin reuptake inhibitors (SSRI) improve depression? a. Destroying increased amounts of serotonin b. Making more serotonin available at the synaptic gap c. Increasing production of acetylcholine and dopamine d. Blocking muscarinic and a1 norepinephrine receptors

Answer 36

ANS: B

Question 37

37. A nurse cares for four patients who are receiving clozapine, lithium, fluoxetine, and venlafaxine, respectively. With which patient should the nurse be most alert for problems associated with fluid and electrolyte imbalance? The patient receiving: a. lithium (Lithobid). c. fluoxetine (Prozac). b. clozapine (Clozaril). d. venlafaxine (Effexor).

Answer 37

ANS: A

Question 38

38. Questions the nurse could ask that would be nonjudgmental when obtaining information about patient use of herbal remedies include: (select all that apply) a. “You don’t regularly take herbal remedies, do you?” b. “What herbal medicines have you used to relieve your symptoms?” c. “What over-the-counter medicines and nutritional supplements do you use?” d. “What differences in your symptoms do you notice when you take herbal supplements?” “Have you experienced problems from using herbal and prescription drugs at the same e. time?”

Answer 38

ANS: B, C, D, E

Question 39

39. An individual is experiencing problems with memory. Which of these structures are most likely to be involved in this deficit? Select all that apply. a. Amygdala b. Hippocampus c. Occipital lobe d. Temporal lobe e. Basal ganglia

Answer 39

ANS: A, B, D

Question 40

``` 40. A newly admitted client is diagnosed with bipolar disorder: manic episode. Which symptom related to altered thought is the nurse most likely to assess? A. Pacing B. Flight of ideas C. Lability of mood D. Irritability ```

Answer 40

ANS: B

Question 41

41. A nurse assesses a client suspected of having major depressive disorder. Which client symptom would eliminate this diagnosis? A. The client is disheveled and malodorous. B. The client refuses to interact with others. C. The client is unable to feel any pleasure. D. The client has maxed-out charge cards and exhibits promiscuous behaviors.

Answer 41

ANS: D

Question 42

42. A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. Which foods should the nurse teach the client to avoid? A. Pepperoni pizza and red wine B. Bagels with cream cheese and tea C. Apple pie and coffee D. Potato chips and diet cola

Answer 42

ANS: A

Question 43

43. A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be taught by the nurse? A. The side effects of medications B. Deep breathing techniques to decrease stress C. How to make eye contact when communicating D. How to be a leader

Answer 43

ANS: C

Question 44

44. A 16-year-old client diagnosed with schizophrenia experiences command hallucinations to harm others. The client’s parents ask a nurse, “Where do the voices come from?” Which is the appropriate nursing reply? A. “Your child has a chemical imbalance of the brain, which leads to altered thoughts.” B. “Your child’s hallucinations are caused by medication interactions.” C. “Your child has too little serotonin in the brain, causing delusions and hallucinations.” D. “Your child’s abnormal hormonal changes have precipitated auditory hallucinations.”

Answer 44

ANS: A

Question 45

45. Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply? A. “Tell him to stop discussing the voices.” B. “Ignore what he is saying, while attempting to discover the underlying cause.” C. “Focus on the feelings generated by the hallucinations and present reality.” D. “Present objective evidence that the voices are not real.”

Answer 45

ANS: C

Question 46

46. An elderly client diagnosed with schizophrenia takes an antipsychotic and a beta-adrenergic blocking agent (propranolol) for hypertension. Understanding the combined side effects of these drugs, the nurse would most appropriately make which statement? A. “Make sure you concentrate on taking slow, deep, cleansing breaths.” B. “Watch your diet and try to engage in some regular physical activity.” C. “Rise slowly when you change position from lying to sitting or sitting to standing.” D. “Wear sunscreen and try to avoid midday sun exposure.”

Answer 46

ANS: C

Question 47

``` 47. A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately? A. Sore throat, fever, and malaise B. Akathisia and hypersalivation C. Akinesia and insomnia D. Dry mouth and urinary retention ```

Answer 47

ANS: A

Question 48

``` 48. If clozapine (Clozaril) therapy is being considered, the nurse should evaluate which laboratory test to establish a baseline for comparison in order to recognize a potentially life- threatening side effect? A. White blood cell count B. Liver function studies C. Creatinine clearance D. Blood urea nitrogen ```

Answer 48

ANS: A

Question 49

49. A college student has quit attending classes, isolates self because of hearing voices, and yells accusations at fellow students. Based on this information, which nursing diagnosis should the nurse prioritize? A. Altered thought processes R/T hearing voices AEB increased anxiety B. Risk for other-directed violence R/T yelling accusations C. Social isolation R/T paranoia AEB absence from classes D. Risk for self-directed violence R/T depressed mood

Answer 49

ANS: B

Question 50

rehabilitative program when planning care for clients diagnosed with schizophrenia? Select all that apply. A. Group therapy B. Medication management C. Deterrent therapy D. Supportive family therapy E. Social skills training

Answer 50

ANS: A, B, D, E

Question 51

51. A suicidal client says to a nurse, “There’s nothing to live for anymore.” Which is the most appropriate nursing reply? A. “Why don’t you consider doing volunteer work in a homeless shelter?” B. “Let’s discuss the negative aspects of your life.” C. “Things will look better in the morning.” D. “It sounds like you are feeling pretty hopeless.”

Answer 51

ANS: D

Question 52

52. A nursing student is developing a plan of care for a suicidal client. Which documented intervention should the student implement first? A. Communicate therapeutically. B. Observe the client. C. Provide a hazard-free environment. D. Assess suicide risk.

Answer 52

ANS: D

Question 53

53. A nurse is caring for four clients diagnosed with major depressive disorder. When considering each client’s belief system, the nurse should conclude which client would potentially be at highest risk for suicide? A. Roman Catholic B. Protestant C. Atheist D. Muslim

Answer 53

ANS: C

Question 54

54. Which nursing intervention strategy is most appropriate to implement initially with a suicidal client? A. Ask a direct question such as, “Do you ever think about killing yourself?” B. Ask client, “Please rate your mood on a scale from 1 to 10.” C. Establish a trusting nurse–client relationship. D. Apply the nursing process to the planning of client care.

Answer 54

ANS: A

Question 55

55. Which client data indicate that a suicidal client is participating in a plan for safety? A. Compliance with antidepressant therapy B. A mood rating of 9/10 C. Disclosing a plan for suicide to staff D. Expressing feelings of hopelessness to nurse

Answer 55

ANS: C

Question 56

56. After a teenager reveals that he is gay, the father responds by beating him. The next morning, the teenager is found hanging in his closet. Which paternal grief responses should a nurse anticipate? Select all that apply. A. “I can’t believe this is happening.” B. “If only I had been more understanding.” C. “How dare he do this to me!” D. “I’m just going to have to accept that he was gay.” E. “Well, that was a selfish thing to do.”

Answer 56

ANS: A, B, C

Question 57

57. Which of the following explanations should a nurse include when teaching parents why is it difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? Select all that apply. A. Bipolar symptoms are similar to attention deficit-hyperactivity disorder symptoms. B. Children are naturally active, energetic, and spontaneous. C. Neurotransmitter levels vary considerably in accordance with age. D. The diagnosis of bipolar disorder cannot be assigned prior to the age of 18. E. Genetic predisposition is not a reliable diagnostic determinant.

Answer 57

ANS: A, B

Question 58

58. A patient who is being seen in the community mental health center for PTSD is being considered for EMDR (Eye Movement Desensitization and Reprocessing) therapy. The nurse is being asked to conduct an assessment to validate the patient’s appropriateness for this treatment. Which of the following pieces of data, collected by the nurse, are most important to document when determining appropriateness for treatment with EMDR? Select all that apply. A. The patient has a history of a seizure disorder. B. The patient has a history of ECT. C. The patient reports suicidal ideation with a plan. D. The patient has been using alcohol in increasing quantities over the last 3 months.

Answer 58

ANS: A, C, D

Question 59

59. A nursing instructor is teaching about the concept of anger. Which student statement indicates the need for further instruction? A. “Anger is physiological arousal.” B. “Anger and aggression are essentially the same.” C. “Anger expression is a learned response.” D. “Anger is not a primary emotion.”

Answer 59

ANS: B

Question 60

60. A nursing instructor is teaching about violence-intervention protocols. Which student statement would indicate the need for further instruction? A. “Administering psychotropic medications can be a part of violence-intervention protocols.” B. “Soothing the client by stroking an arm or shoulder can be a part of violence-intervention protocols.” C. “Applying leather restraints can be a part of violence-intervention protocols.” D. “Calling for assistance is a part of violence-intervention protocols.”

Answer 60

ANS: B

Question 61

61. A client diagnosed with brief psychotic disorder is pacing the milieu and occasionally punches the wall. Which should be the initial nursing action? A. Assertively instruct the client to stop punching the wall. B. Encourage the client to write down feelings in a journal. C. With the help of staff, initiate seclusion protocol. D. Ensure adequate physical space between the nurse and the client.

Answer 61

ANS: D

Question 62

62. The nurse observes a client’s escalating anger. The client begins to pace the hall and shouts, “You all better watch out. I’m going to hurt anyone who gets in my way.” Which should be the priority nursing intervention? A. Calmly tell the client, “Staff will help you to control your impulse to hurt others.” B. Remove other clients from the area and maintain milieu safety. C. Gather a show of force by contacting security for assistance. D. Calmly tell the client, “You will need to be medicated and secluded.

Answer 62

” ANS: B

Question 63

63. The client states, “I get into trouble because I respond violently without thinking. That usually gets me into a mess.” Which nursing reply would be most therapeutic to address this client’s problem? A. “Everybody loses their temper. It’s good that you know that about yourself.” B. “I’ll bet you have some interesting stories to share about overreacting.” C. “Let’s explore methods to help you stop and think before taking action.” D. “It’s good that you are showing readiness for behavioral change.”

Answer 63

ANS: C