Performance

Exit

Mental Health Week 5: Mood and Affect

Due
Feb 9, 2022 by 11:59 pm

Final Score

100%
205 out of 306 questions answered correctly

Completed on
Feb 16, 2022 12:46 pm

Incorrect
(101)
For a hyperactive, manic client who exhibits flight of ideas, which rationale explains why the
client is not eating?
Feels undeserving of the food

Is too busy to take time to eat

Wishes to avoid others in the dining area
Believes that the food is poisoned

Rationale
Hyperactive clients frequently will not take the time to eat because they are overinvolved with everything in
their environment. Feeling undeserving of the food is characteristic of a depressive episode. The client is
unable to sit long enough with the other clients to eat a meal; this is not conscious avoidance. The client
probably gives no thought to food because of overinvolvement with the activities in the environment.

Which side effect would the nurse monitor for in a severely depressed client who received
electroconvulsive therapy (ECT)?
Loss of appetite
Postural hypotension
Total memory loss
Confusion immediately after the treatment
Rationale
The nurse would monitor for confusion immediately after the treatment. The electrical energy passing
through the cerebral cortex during ECT results in a temporary state of confusion after treatment. Loss of
appetite, postural hypotension, and total memory loss are not usual or expected side effects. Memory loss is
usually restored after a few months of treatment.

Which characteristic of clients with antisocial personality disorder would the nurse consider
when planning care?
Engages in many rituals
Is a perfectionist
Exhibits lack of empathy for others
Possesses limited communication skills

Rationale
Exhibits lack of empathy for others is a characteristic of clients with antisocial personality disorder. Clients with
obsessive-compulsive disorder, not antisocial personality disorder, engage in rituals. Clients with obsessive-
compulsive personality disorder are perfectionists. Self-satisfaction is of paramount concern to people with
antisocial personality disorder, and they have little or no concern (empathy) for others. Individuals with
antisocial personality disorder do not possess limited communication skills. They are usually charming on the
surface and can easily con people into doing what they want.

Which condition would be a contraindication to electroconvulsive therapy (ECT)?

 Brain tumor
Type 1 diabetes
Hypothyroid disorder
Urinary tract infection

Rationale
ECT is contraindicated in the presence of a brain tumor, because the treatment causes an increase in
intracranial pressure. ECT is not contraindicated in the presence of diabetes, hypothyroidism, or urinary tract
infection.

Which action would the nurse take for a client who is a psychologist and has questioned the
authority of the treatment team and advised other clients that their treatment plans are
wrong?
Tell the other clients to disregard what the client is saying.
Ignore the client’s disruptive behavior while waiting for it to subside.
Restrict the client’s contact with other clients until the disruptive behavior ceases.
Accept that the client is unable to control this behavior while setting appropriate limits.

Rationale
The nurse would accept that the client is unable to control this behavior while setting appropriate limits.
Clients who are out of control need to have limits set for them. The staff must understand that the client is
not deliberately trying to disrupt the unit. Telling the other clients to disregard what the client is saying is
demeaning the client in the eyes of the other clients and does not address the problem directly. Ignoring the
client will not stop the disruptive behavior; also, the nurse has a responsibility to the other clients. Restricting
the client’s contact with other clients until the disruptive behavior ceases may be done as a last resort, but this
approach would not be used until other alternatives have been explored.

Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize
the right answer when they see it or that the right answer will somehow stand out from the other choices. This
is a dangerous misconception. The more carefully the question is constructed, the more each of the choices
will seem like the correct response.

Which action would the nurse take for a withdrawn client who suddenly screams, bursts
into tears, and runs from the room to the far end of the hallway?
Walk to the end of the hallway where the client is standing.
Accept the action as the impulsive behavior of a sick person.
Ask another client in the dayroom why the client acted in this way.
Document objectively the incident in the client’s record immediately.

Rationale
The nurse would walk to the end of the hallway where the client is standing. This lets the client know that the
nurse is available. It also demonstrates an acceptance of the client. Accepting the action as the impulsive
behavior of a sick person is an avoidance technique; it shows a lack of acceptance of the client as a person.
Another client’s perception of the incident may or may not be valid and it is not that client’s responsibility, it is
the nurse’s responsibility. Although it is important to document the incident in the client’s record, this does
not take precedence over letting the client know the nurse is available if needed.

The nurse would identify which medication as a high-potency medication used to treat
schizophrenia?
Loxapine
Thioridazine
Fluphenazine
Perphenazine

Rationale
Fluphenazine is a high-potency medication used for schizophrenia. Loxapine and perphenazine are medium-
potency medications used to treat schizophrenia. Thioridazine is a low-potency medication used to treat
schizophrenia.

Which term describes a display of anger that is socially unacceptable?

Abuse
 Battery
Aggression
Defensiveness

Rationale
Experiencing and demonstrating anger is a normal human reaction; however, aggression is manifest when
behaviors are socially and emotionally unacceptable. Abuse is a general term that infers physical, sexual,
emotional, or verbal mistreatment of another individual. Battery involves harmful or offensive touching or
physical contact. Defensiveness is protection of oneself against a real or perceived threat.

Which term describes the disturbance in mood and affect seen in clients who are
depressed?
Euphoric
Labile
Expansive
Dysphoric

Rationale
Dysphoric describes feelings of hopelessness and sadness, which are symptomatic of depression. Euphoric is a
feeling of elation and joyfulness; this is often seen in the early manic phase of bipolar disorder. A labile mood
describes a rapid change in mood, for example, clients with dementia may be easily upset and then happy. An
expansive (talkative, exaggerated friendliness) mood is usually associated with the manic phase of bipolar
disorder.

STUDY TIP: Do not change your pattern of study. It obviously has contributed to your being here, so it
worked. If you have studied alone, continue to study alone. If you have studied in a group, form a study group.

Which statement is accurate for adolescent suicide behavior?

Boys account for more attempts compared with girls.

Girls use more dramatic methods compared with boys.

Girls talk more about suicide before attempting it.
Boys are more likely to use lethal methods than are girls.

Rationale
The finding that boys are more likely to use lethal methods than are girls is supported by research; girls
account for 90% of suicide attempts, but boys are three times more successful because of the methods they
use. Statistics do not support the assertion that girls talk more about suicide before attempting it than do boys
or that girls use more dramatic methods than do boys.

In the acute phase of bipolar disorder, manic episode, which biopsychosocial need is the
priority?
Psychological
 Physical
Intellectual
Relational

Rationale
During a manic episode, the excessive hyperactivity increases the risk for cardiac collapse, dehydration,
nutritional deficiencies, and sleep pattern disruption. The client also has increased risk for physical injury
secondary to poor judgment and impulsiveness. The other needs are also important, but during the acute
manic phase, it is difficult for the client and the health care team to work on topics that require focus and
concentration.

Test-Taking Tip: Avoid spending excessive time on any one question. Most questions can be answered in 1 to
2 minutes.

Which action would the nurse take when caring for a severely depressed client?
Play a game of chess with the client.
Allow the client to make personal decisions.
Sit down next to the client at frequent intervals.
Provide the client with frequent periods of time for reflection.
Rationale
The nurse would sit down next to the client at frequent intervals. Sitting down next to the client at frequent
intervals gives the client the nonverbal message that someone cares and views the client as being worthy of
attention and concern. The concentration required for chess is too much for the client at this time. The client
is incapable of making decisions at this time. A severely depressed client does not need frequent periods of
time for reflection. Time alone for reflection can lead to more negative thinking patterns.

Which strategy would the nurse use to help a depressed, withdrawn client who exhibits
sadness through nonverbal behavior?
Increase structured physical activity.
Cope with painful feelings by sharing them.
Decide which unit activities the client can perform.
Improve the ability to communicate with significant others.

Rationale
Sharing painful feelings reduces the isolation and sense of uniqueness that these feelings can cause; sharing
of these feelings usually decreases depression. Increasing structured physical activity or deciding which unit
activities the client can perform will do little to decrease the client’s sadness and does not consider the client’s
low level of energy. Improving the client’s ability to communicate with significant others may be important for
the future, if a problem exists, but the sharing of painful feelings is more important than improving
communication with significant others.
Which action would the nurse take to minimize agitation in a disturbed client?
Ensure constant staff contact.
Increase environmental sensory stimulation.
Limit unnecessary interactions with the client.
Discuss the reasons for the client’s behavior.

Rationale
Limiting unnecessary interactions will decrease stimulation and agitation in a disturbed client. Constant client
and staff contact increases stimulation and agitation. Increasing environmental sensory stimulation bombards
the client’s sensorium and increases agitation. Disturbed clients are not able to discuss reasons for their
behavior; thus this client is unlikely to benefit from a discussion at this time.

Which intervention would the nurse include when developing a plan of care for a client in
the manic phase of bipolar disorder?
Focus the client’s interest in reminiscing.
Encourage the client to talk as much as needed.
Persuade the client to complete any task that has been started.
Redirect the client’s excess energy to more constructive activities.
Rationale
The hyperactive client usually is easily distracted, so excess energy can be redirected into constructive
channels. The client with bipolar disorder, manic phase, does not need to reminisce. The client in the manic
phase will talk a great deal with no encouragement. The client in the manic phase will not be able to focus
long enough on one task to finish it.

Test-Taking Tip: Do not read too much into the question or worry that it is a 'trick.' If you have nursing
experience, ask yourself how a classmate who is inexperienced would answer this question from only the
information provided in the textbooks or given in the lectures.

Which type of sexual disorder describes a client who has a sexual obsession with shoes?
Select all that apply. One, some, or all responses may be correct.
Sexual sadism
Fetishistic
Pedophilic
Voyeuristic
Frotteuristic
Exhibitionistic

Rationale
Having a fetish is to become sexually aroused by something that would not be typically arousing. A fetishistic
disorder is characterized by a sexual focus on objects (such as shoes, gloves, pantyhose, and stockings) that are
intimately associated with the human body. Sadism is achievement of sexual satisfaction from the physical or
psychological suffering (including humiliation) of a victim. Pedophilic disorder is a predominant or exclusive
sexual interest toward prepubescent children. Voyeurism is characterized by seeking sexual arousal through
the viewing (usually secret) of other people engaged in intimate situations. Rubbing or touching a non-
consenting person is frotteuristic disorder. Exhibitionistic disorder involves the intentional display of the
genitals in a public place.

Which therapeutic communication technique would be useful for a client with major
depressive disorder?  Select all that apply.  One, some, or all responses may be correct.
Some correct answers were not selected
Reflecting
Offering self
Using silence
Paraphrasing
Asking open-ended questions
Encouraging comparison

Rationale
Reflection helps clients better understand their own thoughts and feelings. Offering self means the nurse
demonstrates interest and desire to understand. Silence gives clients time to collect their thoughts.
Paraphrasing means to restate the basic content of a client’s message in different, usually fewer, words. The
nurse may confirm an interpretation of the client’s message by using simple, precise, and culturally relevant
terms, before the interview continues. Open-ended questions encourage clients to share information about
experiences. Encouraging comparison brings out recurring themes and helps clients clarify similarities and
differences.

Test-Taking Tip: Do not select answers that contain exceptions to the general rule, controversial material, or
degrading responses.

Which substance is considered addictive in the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5)?Select all that apply. One, some, or all responses may be
correct.
Some correct answers were not selected
Alcohol
Caffeine
Cannabis
Gambling
Hallucinogens
Antianxiety medications
Rationale
Alcohol, caffeine, cannabis, hallucinogens, and antianxiety medications are all considered substances of abuse
in the DSM-5. Tobacco, opioids, inhalants, sedatives, hypnotics, and stimulants are also listed. Behaviors are
gradually being recognized as addictive. For example, gambling was officially declared a disorder in 2013.

Which behavior is an early sign of an abusive personality? Select all that apply. One, some,
or all responses may be correct.
Some correct answers were not selected
Verbal abusive
Jealous, controlling
Enforces rigid sex roles
Hypersensitive, easily insulted
Isolates partner from family and friends
Makes others responsible for their feelings

Rationale
Abuser behavior has several characteristics. A typical abuser has poor emotional control, a superior attitude
toward women, a history of substance abuse, high levels of jealousy and insecurity, and hypersensitivity. Other
characteristics include making others responsible for their feelings and using threats, such as verbal abuse,
punishment, and physical violence, to control another’s behavior. Control may extend to enforcing rigid sex
roles and isolating a partner from family and friends. Early recognition of the characteristics of potential
violence allows for effective intervention.

A child with cystic fibrosis (CF) has been admitted with a respiratory infection. The child has
been very disruptive and angry with staff and parents. Which reason would the nurse
suspect is the cause for the child’s uncooperative behavior?
Spoiled and needs to be adequately disciplined
Resentful of the restriction of the hospitalizations
Having a reaction to the new respiratory medications
Angry about dietary restrictions related to the disease

Rationale
Children with CF often become resentful of repeated hospitalizations, the disease itself, and restrictions on
their activities. It is judgmental to assume that the child is spoiled, and the child has had dietary restrictions in
place since diagnosis of the disease, so this is not a new issue. Although new medications may have side
effects, they are rarely behavioral in nature.

Which characteristic uniquely associated with psychophysiological disorders would

differentiate them from somatic symptom disorders?
Emotional cause
Feeling of illness
 Restriction of activities
Underlying pathophysiology

Rationale
Psychophysiological disorders have an underlying pathophysiology or actual physical cause, whereas somatic
symptom disorders usually do not. The psychophysiological response (e.g., hyperfunction or hypofunction)
produces actual tissue change. Somatic symptom disorders are unrelated to organic changes. There is an
emotional component in both instances. There is a feeling of illness in both instances. There may be a
restriction of activities in both instances.

Which primary feeling would the nurse anticipate that clients with bulimia nervosa
experience after an episode of bingeing?
Guilt
Paranoia
Euphoria
Satisfaction

Rationale
Guilt is a primary feeling clients experience after a bingeing episode. A sense of being out of control
accompanies the consumption of large amounts of food, resulting in guilt, depression, and disgust with one’s
self. Paranoia is associated with schizophrenia and paranoid personality disorder, not with bulimia nervosa.
After bingeing, a person with bulimia nervosa usually feels guilt rather than euphoria or satisfaction because
these clients are aware that the eating pattern is abnormal.

Which action would the nurse take before a severely depressed client receives
electroconvulsive therapy (ECT)?
Have the client speak with other clients undergoing ECT.
Give a detailed explanation of what to expect after the procedure.
Limit the client’s intake to a light breakfast on the days of the treatment.
Provide emotional support while presenting a simple explanation of the ECT procedure.

Rationale
The nurse would provide emotional support while presenting a simple explanation of the ECT procedure. The
nurse would offer support and use clear, simple terms to allay the client’s anxiety. Having the client talk to
ECT recipients may be too frightening or confusing to the client, and the nurse is responsible for educating
the client, not other clients. Severely depressed clients cannot retain long, detailed explanations. The client
generally is kept on nothing-by-mouth status before ECT to prevent aspiration during the procedure.

Which action by the school nurse would be most important when monitoring an adolescent
who has just returned to high school after a suicide attempt?
Observe the adolescent interacting with friends.
 Request that teachers and friends report any changes in the client’s behavior.
Speak with the adolescent regarding feelings about returning to school.
Tell the teachers what happened and ask them whether there are any problems.

Rationale
The most important action is speaking to the adolescent because the best person to obtain data from is the
adolescent. Speaking with the adolescent regarding feelings about returning to school shows the adolescent
that the nurse is available and is interested and concerned. Observing the adolescent interacting with friends
is appropriate, but it is not the most important because this does not provide the best information; the
adolescent would provide the best information. Requesting that teachers and friends report any changes in
behavior will place responsibility on others and may interfere with the adolescent’s relationship with them.
Also, it violates the adolescent’s right to privacy. Telling the teachers what happened and asking whether there
are any problems violates the adolescent’s right to privacy.

STUDY TIP: Avoid planning other activities that will add stress to your life between now and the time you take
the licensure examination. Enough will happen spontaneously; do not plan to add to it.

In light of a nurse hearing a depressed client telling another client, 'I’ll be feeling better
soon,' which initial parameter would the nurse assess for in the depressed client?
Ability to sleep
Suicidal thinking
Current feelings of depression
 Subjective ideas about treatment progress

Rationale
The nurse would assess the client’s suicidal thinking. The client’s comment reflects the possibility of suicide;
further assessment and protection of the client are necessary. Although sleep is affected by depression, the
overheard comment does not make this a priority at this time. Although feelings of depression could be
getting better and subjective ideas about treatment progress could be improving, neither is the priority at this
time. These assessments can be addressed after the assessment for suicide.

Which response would the nurse make to a client scheduled for electroconvulsive therapy
(ECT) who says, 'I’m scared that I’ll lose my memory forever after the treatment'?
'Your memory loss may be permanent, but usually it’s just temporary.'
'You won’t experience a permanent memory loss, so there’s no need to be frightened.'
'You’ll experience a temporary loss of memory, and feeling frightened about it is expected.'
'Your memory loss will be temporary, and it will help block out many of your painful past experiences.'

Rationale
The nurse would respond with, 'You’ll experience a temporary loss of memory, and feeling frightened about it
is expected.' Giving the client simple facts and assuring the client that being frightened is expected may help
ease the client’s fears. Memory loss affects recently learned information such as the ECT experience; the
response that it may be permanent may unnecessarily worry the client. Although it is a true statement that
memory loss is not permanent and there is no need to worry, this response negates the client’s feelings. ECT
does not selectively block out painful experiences.

Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct
answer.

A client with hepatic cirrhosis begins to exhibit slurred speech, confusion, drowsiness, and a
flapping tremor. Based upon this assessment, which prescribed diet would the nurse
anticipate?
No protein
Moderate protein
High protein
Strict protein restriction

Rationale
Because the liver is unable to detoxify ammonia to urea and the client is experiencing clinical manifestations
leading to an impending hepatic encephalopathy coma, protein intake should be moderate. Strict protein and
no-protein restrictions are not required because the client needs protein for healing. The hepatic
encephalopathy diagnosis contradicts high-protein intake because protein breaks down into ammonia.

Test-Taking Tip: After choosing an answer, go back and reread the question stem along with your chosen
answer. Does it fit correctly? The choice that grammatically fits the stem and contains the correct information
is the best choice.

The nurse is working with an older adult brought to the emergency department after
sustaining multiple falls at home. The nurse suspects alcohol abuse. Which finding places
the client at risk for injury?
Depression
Self-neglect
Malnutrition
Lack of insight

Rationale
Lack of insight can occur in older adults who have excessive alcohol intake. This can place the client at risk for
injury because the client is unable to think through the ramifications of his or her actions. Depression, self-
neglect, and malnutrition are physical and mental manifestations of alcohol abuse but do not directly place
the client at risk for injury.

Test-Taking Tip: Look for options that are similar in nature. If all are correct, either the question is poor or all
options are incorrect, the latter of which is more likely. Example: If the answer you are seeking is directed to a
specific treatment and all but one option deal with signs and symptoms, you would be correct in choosing the
treatment-specific option.
The nurse is working with a group of clients in a mental health facility. The nurse would
assess risk for suicide in clients with which conditions? Select all that apply. One, some, or
all responses may be correct.
Some correct answers were not selected
Anxiety
Alcohol abuse
Schizophrenia
Bipolar disorder
Attention deficit disorder

Rationale
Certain mental health disorders increase a person’s risk for suicide. These include anxiety, alcohol abuse,
schizophrenia, and bipolar disorder. Attention deficit disorder does not increase a person’s risk for suicide.

The nurse is discussing suicide risk with the parents of a group of adolescents. Which types
of suicide would the nurse discuss when talking about soft methods? Select all that apply.
One, some, or all responses may be correct.
Guns
Hanging
Ingesting pills
 Carbon monoxide
Cutting one’s wrists

Rationale
Ingesting pills and cutting one’s wrists are lower-risk methods and are soft methods. Higher-risk methods
include using guns, hanging, or carbon monoxide.

Which actions by the staff of a mental health unit can lead to client violence? Select all that
apply. One, some, or all responses may be correct.
Displaying hyperactivity
Inconsistent limit setting
Controlling staff members
Avoiding direct eye contact
Randomly taking away privileges

Rationale
Actions that occur in the mental health unit can increase the risk for client violence. These include
inconsistent limit setting, staff members who are controlling, and randomly taking away privileges from
clients. Hyperactivity and avoiding direct eye contact do not present the same risk.

Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or
clinical changes (or both) within a certain time, can provide a clue to the most appropriate response or, in some
cases, responses.

Which intervention would the nurse use to promote the safety of a client experiencing
alcohol withdrawal?
Infuse intravenous fluids.
Monitor the level of anxiety.
Obtain frequent vital signs.
Administer chlordiazepoxide.

Rationale
The nurse would administer chlordiazepoxide to prevent injury because alcohol withdrawal can cause seizures
and autonomic hyperactivity. Administering intravenous fluids maintains hydration. Monitoring anxiety levels
does not affect client safety. Obtaining frequent vital signs allows the nurse to assess for autonomic
hyperactivity but does not directly affect client safety.

The nurse is preparing to administer methylphenidate to an older adult with apathy and
depression. Which would the nurse include in the assessment to monitor for
complications? Select all that apply. One, some, or all responses may be correct.
Some correct answers were not selected
 Vision
Weight
Heart rate
Skin turgor
Bowel sounds

Rationale
When methylphenidate is administered to older adults, the nurse will monitor the client’s vision for signs of
glaucoma, as well as their weight, heart rate, and blood pressure. Skin turgor and bowel sounds are not
affected by methylphenidate.

Test-Taking Tip: Avoid spending excessive time on any one question. Most questions can be answered in 1 to
2 minutes.

A client has been receiving lithium for the past 2 weeks for the treatment of bipolar
disorder, manic phase. Which information will the nurse include in the teaching plan for
this client?
A diuretic is necessary for anyone taking lithium.
Lithium must be taken for the rest of the client’s life.
The blood level of lithium must be checked every month.
 A low-sodium diet must be followed while lithium is being taken.

Rationale
Lithium’s therapeutic window is very narrow, and a toxic level may accumulate in the body unless routine
checks of the medication’s concentration in the blood are performed. During the acute phase of mania, the
therapeutic blood level of lithium should be between 1.0 and 1.5 mEq/L (1.0–1.5 mmol/L); the maintenance
therapeutic blood level of lithium ranges from 0.5 and 1.2 mEq/L (0.5–1.2 mmol/L). Diuretics reduce sodium
and should be avoided; lithium is not excreted when the sodium level is decreased, resulting in toxicity.
Lithium may or may not need to be taken for the rest of a client’s life. A low-sodium diet can lead to
hyponatremia, which must be avoided because it limits the excretion of lithium, resulting in toxicity.

Test-Taking Tip: Become familiar with reading questions on a computer screen. Familiarity reduces anxiety
and decreases errors.

Which side effect would the nurse monitor for when administering a selective serotonin
reuptake inhibitor (SSRI)? Select all that apply. One, some, or all responses may be correct.
Some correct answers were not selected
Anxiety
Nausea
Sedation
Restlessness
Suicidal ideation
 Increased energy level

Rationale
Clients on SSRIs would be assessed for changes in attitude (anxiety, restlessness) and suicidal gestures.
Depressed people may attempt suicide when taking antidepressants as a result of increased energy levels,
which can lead to a renewed interest in suicide. Other side effects of SSRIs include nausea, sedation, dry
mouth, vomiting, constipation, diarrhea, anorexia, differences in taste, headache, tremor, dizziness, weakness,
fatigue, increased sweating, sexual dysfunction, visual disturbances, and urinary problems.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked
to select all options that apply to a given situation or client. All options likely relate to the situation, but only
some of the options may relate directly to the situation.

Which characteristic mental change occurs with delirium and differentiates it from
dementia?  Select all that apply. One, some, or all responses may be correct.
Daytime sleepiness
Rapid-onset confusion
Lasts over several years
Progressive deterioration
Apathetic thought process
Rationale
The mental changes associated with delirium have a rapid onset and are usually precipitated by an infection or
medication change. Clients with dementia may sleep more during the day, and the duration of the disease
lasts several years with a progressive deterioration of body systems. Clients with depression may display
apathy, but this mental change is not specific to delirium or dementia.

For a hyperactive, manic client who exhibits flight of ideas, which rationale explains why the
client is not eating?
Feels undeserving of the food
Is too busy to take time to eat
Wishes to avoid others in the dining area
Believes that the food is poisoned

Rationale
Hyperactive clients frequently will not take the time to eat because they are overinvolved with everything in
their environment. Feeling undeserving of the food is characteristic of a depressive episode. The client is
unable to sit long enough with the other clients to eat a meal; this is not conscious avoidance. The client
probably gives no thought to food because of overinvolvement with the activities in the environment.

Which characteristic of clients with antisocial personality disorder would the nurse consider
when planning care?
 Engages in many rituals
Is a perfectionist
Exhibits lack of empathy for others
Possesses limited communication skills

Rationale
Exhibits lack of empathy for others is a characteristic of clients with antisocial personality disorder. Clients with
obsessive-compulsive disorder, not antisocial personality disorder, engage in rituals. Clients with obsessive-
compulsive personality disorder are perfectionists. Self-satisfaction is of paramount concern to people with
antisocial personality disorder, and they have little or no concern (empathy) for others. Individuals with
antisocial personality disorder do not possess limited communication skills. They are usually charming on the
surface and can easily con people into doing what they want.

Which action would the nurse take for a withdrawn client who suddenly screams, bursts
into tears, and runs from the room to the far end of the hallway?
Walk to the end of the hallway where the client is standing.
Accept the action as the impulsive behavior of a sick person.
Ask another client in the dayroom why the client acted in this way.
Document objectively the incident in the client’s record immediately.
Rationale
The nurse would walk to the end of the hallway where the client is standing. This lets the client know that the
nurse is available. It also demonstrates an acceptance of the client. Accepting the action as the impulsive
behavior of a sick person is an avoidance technique; it shows a lack of acceptance of the client as a person.
Another client’s perception of the incident may or may not be valid and it is not that client’s responsibility, it is
the nurse’s responsibility. Although it is important to document the incident in the client’s record, this does
not take precedence over letting the client know the nurse is available if needed.

In the acute phase of bipolar disorder, manic episode, which biopsychosocial need is the
priority?
Psychological
Physical
Intellectual
Relational

Rationale
During a manic episode, the excessive hyperactivity increases the risk for cardiac collapse, dehydration,
nutritional deficiencies, and sleep pattern disruption. The client also has increased risk for physical injury
secondary to poor judgment and impulsiveness. The other needs are also important, but during the acute
manic phase, it is difficult for the client and the health care team to work on topics that require focus and
concentration.

Test-Taking Tip: Avoid spending excessive time on any one question. Most questions can be answered in 1 to
2 minutes.

Which action would the nurse take when caring for a severely depressed client?
Play a game of chess with the client.
Allow the client to make personal decisions.
Sit down next to the client at frequent intervals.
Provide the client with frequent periods of time for reflection.

Rationale
The nurse would sit down next to the client at frequent intervals. Sitting down next to the client at frequent
intervals gives the client the nonverbal message that someone cares and views the client as being worthy of
attention and concern. The concentration required for chess is too much for the client at this time. The client
is incapable of making decisions at this time. A severely depressed client does not need frequent periods of
time for reflection. Time alone for reflection can lead to more negative thinking patterns.

Which strategy would the nurse use to help a depressed, withdrawn client who exhibits
sadness through nonverbal behavior?
Increase structured physical activity.
Cope with painful feelings by sharing them.
Decide which unit activities the client can perform.
 Improve the ability to communicate with significant others.

Rationale
Sharing painful feelings reduces the isolation and sense of uniqueness that these feelings can cause; sharing
of these feelings usually decreases depression. Increasing structured physical activity or deciding which unit
activities the client can perform will do little to decrease the client’s sadness and does not consider the client’s
low level of energy. Improving the client’s ability to communicate with significant others may be important for
the future, if a problem exists, but the sharing of painful feelings is more important than improving
communication with significant others.

Which action would the nurse take to minimize agitation in a disturbed client?
Ensure constant staff contact.
Increase environmental sensory stimulation.
Limit unnecessary interactions with the client.
Discuss the reasons for the client’s behavior.

Rationale
Limiting unnecessary interactions will decrease stimulation and agitation in a disturbed client. Constant client
and staff contact increases stimulation and agitation. Increasing environmental sensory stimulation bombards
the client’s sensorium and increases agitation. Disturbed clients are not able to discuss reasons for their
behavior; thus this client is unlikely to benefit from a discussion at this time.
Which substance is considered addictive in the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5)?Select all that apply. One, some, or all responses may be
correct.
Some correct answers were not selected
Alcohol
Caffeine
Cannabis
Gambling
Hallucinogens
Antianxiety medications

Rationale
Alcohol, caffeine, cannabis, hallucinogens, and antianxiety medications are all considered substances of abuse
in the DSM-5. Tobacco, opioids, inhalants, sedatives, hypnotics, and stimulants are also listed. Behaviors are
gradually being recognized as addictive. For example, gambling was officially declared a disorder in 2013.

Which behavior is an early sign of an abusive personality? Select all that apply. One, some,
or all responses may be correct.
Some correct answers were not selected
Verbal abusive
 Jealous, controlling
Enforces rigid sex roles
Hypersensitive, easily insulted
Isolates partner from family and friends
Makes others responsible for their feelings

Rationale
Abuser behavior has several characteristics. A typical abuser has poor emotional control, a superior attitude
toward women, a history of substance abuse, high levels of jealousy and insecurity, and hypersensitivity. Other
characteristics include making others responsible for their feelings and using threats, such as verbal abuse,
punishment, and physical violence, to control another’s behavior. Control may extend to enforcing rigid sex
roles and isolating a partner from family and friends. Early recognition of the characteristics of potential
violence allows for effective intervention.

Which action would the nurse take before a severely depressed client receives
electroconvulsive therapy (ECT)?
Have the client speak with other clients undergoing ECT.
Give a detailed explanation of what to expect after the procedure.
Limit the client’s intake to a light breakfast on the days of the treatment.
Provide emotional support while presenting a simple explanation of the ECT procedure.
Rationale
The nurse would provide emotional support while presenting a simple explanation of the ECT procedure. The
nurse would offer support and use clear, simple terms to allay the client’s anxiety. Having the client talk to
ECT recipients may be too frightening or confusing to the client, and the nurse is responsible for educating
the client, not other clients. Severely depressed clients cannot retain long, detailed explanations. The client
generally is kept on nothing-by-mouth status before ECT to prevent aspiration during the procedure.

Which action by the school nurse would be most important when monitoring an adolescent
who has just returned to high school after a suicide attempt?
Observe the adolescent interacting with friends.
Request that teachers and friends report any changes in the client’s behavior.
Speak with the adolescent regarding feelings about returning to school.
Tell the teachers what happened and ask them whether there are any problems.

Rationale
The most important action is speaking to the adolescent because the best person to obtain data from is the
adolescent. Speaking with the adolescent regarding feelings about returning to school shows the adolescent
that the nurse is available and is interested and concerned. Observing the adolescent interacting with friends
is appropriate, but it is not the most important because this does not provide the best information; the
adolescent would provide the best information. Requesting that teachers and friends report any changes in
behavior will place responsibility on others and may interfere with the adolescent’s relationship with them.
Also, it violates the adolescent’s right to privacy. Telling the teachers what happened and asking whether there
are any problems violates the adolescent’s right to privacy.

STUDY TIP: Avoid planning other activities that will add stress to your life between now and the time you take
the licensure examination. Enough will happen spontaneously; do not plan to add to it.

The nurse is discussing suicide risk with the parents of a group of adolescents. Which types
of suicide would the nurse discuss when talking about soft methods? Select all that apply.
One, some, or all responses may be correct.
Guns
Hanging
Ingesting pills
Carbon monoxide
Cutting one’s wrists

Rationale
Ingesting pills and cutting one’s wrists are lower-risk methods and are soft methods. Higher-risk methods
include using guns, hanging, or carbon monoxide.

Which actions by the staff of a mental health unit can lead to client violence? Select all that
apply. One, some, or all responses may be correct.
Displaying hyperactivity
 Inconsistent limit setting
Controlling staff members
Avoiding direct eye contact
Randomly taking away privileges

Rationale
Actions that occur in the mental health unit can increase the risk for client violence. These include
inconsistent limit setting, staff members who are controlling, and randomly taking away privileges from
clients. Hyperactivity and avoiding direct eye contact do not present the same risk.

Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or
clinical changes (or both) within a certain time, can provide a clue to the most appropriate response or, in some
cases, responses.

Which intervention would the nurse use to promote the safety of a client experiencing
alcohol withdrawal?
Infuse intravenous fluids.
Monitor the level of anxiety.
Obtain frequent vital signs.
Administer chlordiazepoxide.
Rationale
The nurse would administer chlordiazepoxide to prevent injury because alcohol withdrawal can cause seizures
and autonomic hyperactivity. Administering intravenous fluids maintains hydration. Monitoring anxiety levels
does not affect client safety. Obtaining frequent vital signs allows the nurse to assess for autonomic
hyperactivity but does not directly affect client safety.

The nurse is preparing to administer methylphenidate to an older adult with apathy and
depression. Which would the nurse include in the assessment to monitor for
complications? Select all that apply. One, some, or all responses may be correct.
Some correct answers were not selected
Vision
Weight
Heart rate
Skin turgor
Bowel sounds

Rationale
When methylphenidate is administered to older adults, the nurse will monitor the client’s vision for signs of
glaucoma, as well as their weight, heart rate, and blood pressure. Skin turgor and bowel sounds are not
affected by methylphenidate.

Test-Taking Tip: Avoid spending excessive time on any one question. Most questions can be answered in 1 to
2 minutes.

Doxepin is prescribed for a 74-year-old client to treat a depressive episode. Which side
effects would the nurse include when teaching the client about doxepin? Select all that
apply. One, some, or all responses may be correct.
Some correct answers were not selected
Diarrhea
Loss of appetite
Photosensitivity
Urine retention
Suicidal ideation

Rationale
Doxepin, because of its significant anticholinergic properties, can lead to urine retention, particularly in older
men. Doxepin may cause an increase in psychiatric symptoms and precipitate suicidal ideation. It may cause
constipation, not diarrhea. Doxepin may cause an increase, not a decrease, in appetite. Although
photosensitivity is an unusual side effect of doxepin, it can be managed through nursing interventions such as
avoiding the sun, wearing protective clothing, and using sunblock.

A client, readmitted for exacerbation of ulcerative colitis, is weak, thin, and irritable. The
client states, 'I am now ready for the surgery to create an ileostomy.' Which nursing
intervention best meets the client’s needs at this time?
Parenterally replace the client’s fluids and electrolytes.
Adjust client’s diet to promote weight gain.
Provide anticipatory teaching on the use of ileostomy appliances.
Encourage client interaction with other clients who have an ileostomy.

Rationale
When a client has an ulcerative colitis exacerbation, the client may have more than 10 stools per day, and the
stools are bloody and full of mucus. The client can become dehydrated and lose vital electrolytes. Parenterally
replacing fluids and electrolytes is a life-saving strategy; replacement occurs before performing the surgery to
stabilize the client. Helping the client regain former body weight is not the priority at this time. The client is
neither physically nor cognitively ready to learn the psychomotor skill of how to manage an ileostomy. The
client is not demonstrating a readiness for contact with other persons with ileostomies at this time.

STUDY TIP: Record the information you find to be most difficult to remember on 3' × 5' cards and carry them
with you in your pocket or purse. When you are waiting in traffic or for an appointment, just pull out the cards
and review again. This 'found' time may add points to your test scores that you have lost in the past.

Which part of the female genitalia protects inner vulval structures and enhances sexual
arousal?
Clitoris
 Mons pubis
Labia majora
Bartholin glands

Rationale
The labia majora are two vertical folds of adipose tissue that protects the inner vulval structures and enhances
sexual arousal. The clitoris is a small, cylindrical organ that becomes larger and increases sexual sensation.
The mons pubis is a fat pad that covers and protects the symphysis pubis during coitus. The Bartholin glands
are located near the vaginal opening; they secrete lubricating fluid during sexual excitement.

Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If
you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your
knowledge, skills, and abilities to choose from the remaining responses.

Which intervention would the nurse implement for a client with delirium? Select all that
apply. One, some, or all responses may be correct.
Providing consistency
Minimizing client fears
Using physical restraints
Asking orientation questions
Involving the client in decision-making
 Administering prn medications for anxiety

Rationale
Providing a consistent physical environment, daily routine, and caregivers, as well as acknowledging the
client’s fears and feelings, are important components of caring for clients with delirium. Physical restraints
may increase symptoms and would be avoided if possible. Family members can assist in maintaining safety to
avoid restraint use. The neurological status of delirious clients would be monitored on an ongoing basis;
however, the nurse would avoid quizzing with orientation questions that cannot be answered as this can
frustrate clients. If decision-making is frustrating or confusing for a client, it would be limited. As-needed
(prn) medications for anxiety or agitation would be used with caution in clients with delirium.

Which statements listed by the nursing student are appropriate regarding theories related
to temperament? Select all that apply. One, some, or all responses may be correct.
An easy child is open and adaptable to changes.
A difficult child requires a more structured environment.
A difficult child shows an intense and primarily negative mood.
A slow-to-warm up child displays a mild to moderately intense mood.
A difficult child reacts negatively and with mild intensity to new stimuli.

Rationale
The nurse would know that an easy child is open and adaptable to changes. A difficult child requires a more
structured environment and shows an intense and primarily negative mood. An easy child displays a mild to
moderately intense mood. A slow-to-warm up child reacts negatively and with mild intensity to new stimuli.

Which clinical manifestation is associated with depression?

Flight of ideas
Suspicion of others
Psychomotor retardation
Intrusive social behaviors

Rationale
Both thought and motor activity, which require physical and psychic energy, are commonly slowed when
someone is depressed. Flight of ideas is associated with manic behavior because it requires psychic energy.
Suspicion is associated with paranoid ideation and is less common with depression. Intrusive social behaviors
are associated with manic behavior.

For a client with the diagnosis of borderline personality disorder, which problem is most
likely to underlie angry or hostile behavior?
Low self-esteem
Inability to test reality
Reaction to command hallucination
 Ineffective verbal communication

Rationale
The client has low self-esteem and reacts by using hostile behavior. People with borderline personality
disorder often have identity disturbances. Reality testing and hallucinations are psychotic features that do not
accompany personality disorders. Impaired verbal communication can be related to organic causes, such as
stroke or dementia, or to thought disturbances, such as schizophrenia.

The client reports screaming hysterically whenever a spider comes close to her. Which
defense mechanism is the client using?
Sublimation
Displacement
Repression
Introjection

Rationale
The defense mechanism of displacement is related to phobias; displacement is the release of pent-up feelings
onto something or someone else that is less threatening than the original source of the feelings. Sublimation
is the channeling of unacceptable impulses into constructive acceptable behaviors. Repression is the
unconscious process of blocking awareness of unacceptable ideas or impulses. Introjection is treating
something outside the self as if it is inside the self. Sublimation, repression, and introjection are unrelated to
phobias.

Which behavior would the nurse observe in a child with oppositional defiant disorder?
Has excessive anxiety
Destroys property
Violates the rights of others
Deliberately annoys others

Rationale
The nurse would observe a child who deliberately annoys others. Excessive anxiety occurs with anxiety
disorders, not oppositional defiant disorder. Children with oppositional defiant disorder do not destroy
property or violate the rights of others. Conduct disorder is characterized by a pattern of behavior in which the
rights of others and social norms or rules are violated (destroying property).

Which strategy would be effective for a client with alcohol use disorder who says, 'Drinking
is a way out of my depression'?
A self-help group
Psychoanalytical therapy
A visit with a religious advisor
 Talking with an alcoholic friend

Rationale
A self-help group would be an effective strategy. Members of self-help groups, particularly Alcoholics
Anonymous, are living with the problem themselves; therefore, problem identification and self-responsibility
are emphasized, and manipulation is limited. Psychoanalytical therapy is long-term and tends to increase
anxiety until resolution occurs; level of commitment and duration of therapy render it a less desirable choice
for substance abusers. Depending on the client's feelings about religion, talking with a religious advisor may
or may not be helpful. Whether talking with an alcoholic friend will be useful depends on the friend’s drinking
status; it may be helpful or harmful. These variables negate the effectiveness of this choice.

STUDY TIP: Avoid planning other activities that will add stress to your life between now and the time you take
the licensure examination. Enough stressful activities will happen spontaneously; do not plan to add to it.

For a client with bipolar I disorder, manic episode, which factor would be considered to
meet rest and sleep needs?
Experiences few sleep pattern disturbances
Requires less sleep than the average person
Is easily stimulated, and this interferes with sleep
Needs to expend energy to be tired enough to sleep
Rationale
Manic individuals readily respond to environmental cues. Increased stimulation increases activity; decreased
stimulation decreases activity. Sleep pattern disturbances characteristically occur because of psychomotor
activity. All individuals require adequate rest and sleep; hyperactive clients may become exhausted because of
their high activity level. Expending energy only increases the tendency to remain awake.

Test-Taking Tip: When using this program, be sure to note if you guess at an answer. This will permit you to
identify areas that need further review. Also, it will help you see how correct your guessing can be.

Which action would the nurse use to establish a therapeutic relationship with a withdrawn,
reclusive client?
Help the client keep anxiety to a minimum.
Protect the client from self-destructive tendencies.
Ascertain what topics are of interest to the client.
Obtain a history from the family before talking with the client.

Rationale
Creating an environment that eases anxiety promotes a feeling of security; as this continues, a sense of trust is
established. The client is not currently exhibiting self-destructive tendencies. Topics of interest are less
important in the beginning phase of a relationship. Obtaining a history from the family is not required to
establish a therapeutic nurse-client relationship.
Which defense mechanism is most often used by parents who abuse an infant or toddler?
Identification
Denial
Rationalization
Displacement

Rationale
Displacement is a defense mechanism in which one's pent-up feelings toward others who are a threat are
discharged on others who are less threatening. Identification is the unconscious wish to be like another
person. Denial is ignoring, avoiding, or refusing to recognize painful realities. Rationalization is making
acceptable or plausible excuses for an undesirable behavior.

A client experienced a second spontaneous abortion and expresses anger toward the health
care provider, the hospital, and the 'rotten nursing care.' Which coping mechanism is the
client displaying?
Denial
Projection
Displacement
Reaction formation
Rationale
The client's anger about the spontaneous abortion is shifted (displacement) to the staff and the hospital
because she is unable to cope with her loss at this time. The client is neither ignoring nor refusing (denial) to
recognize reality. The client is not attributing unacceptable or undesirable thoughts or feelings to another
(projection); nor is she exhibiting a behavior pattern opposite to what she feels (reaction formation).

Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the
correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in 1
or 2 of the options . Example: If the item relates to and identifies stroke rehabilitation as its focus and only 1 of the
options contains the word stroke in relation to rehabilitation, you are safe in identifying this choice as the correct
response.

After a spontaneous abortion at 5 months, a client is depressed and describes how the child
would have looked and how bright he would have been. Which grief pattern is the client
demonstrating?
Disenfranchised grief
Acute grieving
Complicated grieving
Anticipatory grief

Rationale
The client is grieving the loss of a fantasized child; talking about the loss is part of the normal acute grieving
process. Disenfranchised grief is an intense loss, but without a socially recognized relationship (e.g., death of a
pet). Complicated grieving is prolonged and interferes with normal function. Anticipatory grieving precedes
an event that is going to occur (e.g., scheduled mastectomy).

Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when 4 or 5 consecutive
questions have the same letter or number for the correct answer.

Which initial action would the nurse take for a client with bipolar I disorder, manic episode
who becomes loud and vulgar and disturbs the other clients?
Tell the client that the behavior is bothering the other clients.
Ignore the vulgar talk because it is part of the illness.
Take the client to a large, quiet area to walk.
Comment that this kind of talk is not appreciated on the unit.

Rationale
The nurse would initially take the client to a large, quiet area to walk. During the manic phase, when clients
are unable to control their behavior, they should be protected from embarrassing themselves or harming
others. These clients are unable to deal with others’ feelings; the client’s own feelings are primary at this time.
Also, simply telling the client that the behavior is bothersome is too general to communicate which behaviors
are dysfunctional. The client’s behavior cannot be ignored, because the client or others may be hurt if limits
are not set. Stating that this kind of talk is not appreciated on the unit is critical of the client, who is unable to
respond differently at this time. However, after the anxiety has decreased, limits must be set.

Which response would the nurse make to a client with a borderline personality disorder
who cries bitterly and pounds the bed in frustration after a conference with the primary
health care provider?
Leave the client for a short period and wait until the client regains control.
Pat the client reassuringly on the back and say, 'I know that it’s hard to bear.'
Ask about the client’s troubles and answer, 'Other people also have problems.'
Stay with the client and listen attentively if the client wishes to talk about the problem.

Rationale
The nurse would stay with the client and listen attentively if the client wishes to talk about the problem. Sitting
with the client indicates acceptance and demonstrates that the nurse believes the client is worthy of the
nurse’s time. It is better to stay with the client quietly until control is regained; staying prevents the outburst
from escalating. Patting the client reassuringly on the back and saying, 'I know that it’s hard to bear' provides
little comfort for the client; touching should be used judiciously in this instance. Asking about the client’s
troubles and answering, 'Other people also have problems' may close off further communication and belittles
the client’s problems.

Which action would the nurse take for a toddler with autism spectrum disorder who is
sitting in a corner, rocking and spinning a top?
 Hold the toddler to provide a sense of security.
Stroke the toddler’s arm gently to gain the child’s attention.
Wait for the toddler to make the initial contact before moving close.
Sit with the toddler while watching the spinning top to provide a nonintrusive presence.

Rationale
The nurse would sit with the toddler while watching a spinning top to provide a nonintrusive presence.
Children with autism spectrum disorder relate best with objects, which can be used as a bridge in
interpersonal relationships; this begins at the child’s level. Autistic children often become agitated when
movement is restricted and personal space is invaded such as when holding the child. Children with autism
spectrum disorder usually have difficulty tolerating being touched (stroking the toddler’s arm). Autistic
children will not initiate contact or interactions with others. Thus, the nurse cannot wait for the child to make
contact before moving close.

STUDY TIP: Identify your problem areas that need attention. Do not waste time on restudying information
you know.

When a client is clearly demonstrating crisis behavior, which client-focused intervention

would the nurse implement first?
Encourage the client to breathe deep.
Assure the client that he or she is in a safe environment.
 Determine the client’s present state of mind.
Ask whether the client can identify coping mechanisms.

Rationale
The initial focus of this client’s care is to determine the client’s present state of mind. Crisis intervention
focuses on the here and now. Although encouraging the client to breathe deep, assuring the client that he or
she is safe, and determining whether the client can identify coping mechanisms are appropriate actions, they
would not be implemented until the client’s state of mind is determined.

During an assessment the client mentions taking cefotetan and drinking a few cocktails at
dinner. Which symptoms might be explained by this medication–alcohol interaction? Select
all that apply. One, some, or all responses may be correct.
Some correct answers were not selected
Pruritus
Diaphoresis
Hypotension
Hypertension
Stomach cramps
Chest pain
Rationale
Individuals taking the antibiotic cefotetan need to avoid alcohol. Drinking alcohol while on this medication
causes acute alcohol intolerance, resulting in pruritus, diaphoresis, hypotension, and stomach cramps.
Hypertension and chest pain or pressure are not typical symptoms of acute alcohol intolerance and cannot be
explained by this medication–alcohol interaction.

Which response would the nurse make to help a depressed client who is crying?
'Does crying help?'
'I know that you’re upset.'
'Tell me what you’re feeling now.'
'Do you want to tell me why you’re crying?'

Rationale
The nurse would make the response, 'Tell me what you’re feeling now.' This therapeutic response encourages
expression of the client’s feelings. Asking, 'Does crying help?' does not explore feelings, and the client may
interpret it as a put-down. Although the statement, 'I know that you’re upset,' appears empathic, it does not
encourage expression of feelings and the nurse is making an assumption because crying does not always
indicate being upset. Asking, 'Do you want to tell me why you’re crying?' will elicit a yes or no response rather
than encouraging expression of feelings.

Which action would the nurse take for a frail, depressed, older client who frequently paces
the halls and becomes physically tired from the activity?
 Restrain the client in a chair.
Have the client perform simple, repetitive tasks.
Ask the client’s primary health care provider to prescribe a sedative.
Place the client in a single room to limit pacing to a smaller area.

Rationale
The nurse would have the client perform simple, repetitive tasks. Clients who pace can usually be distracted by
planned involvement in repetitious, simple tasks. Restraining the client in a chair is abusive treatment for a
client with a need to pace. The client’s primary health care provider should be asked to prescribe a sedative
only if the client’s restlessness cannot be controlled with other measures and the physical exhaustion creates a
danger. The client may perceive being placed in a single room as a punishment, and it will limit the staff ’s
ability to observe the client.

Which response would the nurse make to a depressed client who tells the nurse, 'I want to
die'?
'You would rather not live.'
'You’re not alone in feeling this way.'
'When was the last time you felt this way?'
'Do you believe that there’s life after death?'
Rationale
The nurse would use the response, 'You would rather not live.' This statement uses paraphrasing to
demonstrate to the client that it is alright to talk about these feelings; it recognizes the client’s sense of
hopelessness without intensifying the feeling while providing an opportunity for the client to verbalize further.
Although it may be true that others feel the same way, this statement takes the focus away from the client.
Finding out when the client last felt this way is insignificant at this time; this question might be appropriate
after the client’s feelings have been validated and discussed. Asking the client about a belief in life after death
takes the focus off the client’s feelings and places it on a philosophical level.

Which response would the nurse take when a client comes up and shouts, 'I hate you!
You’re talking about me again!' and throws a glass of juice at the nurse who is talking to
another client?
Repeating the client’s words and asking for clarification
Removing the client from the room because limits must be placed on such behavior
Ignoring both the behavior and the client, cleaning up the juice, and talking with the client later
Verbalizing feelings of annoyance as an example to the client that it is more acceptable to verbalize
feelings than to act them out

Rationale
The nurse would remove the client from the room because limits must be placed on such behavior. The
client’s behavior is escalating and unsafe. The client should be removed from the room and taken to a place
where there is less environmental stimulation and less chance to act out against others. Repeating the client’s
words and asking for clarification accepts the physical abuse, which should never be done. The behavior and
the client should never be ignored; the client needs limits set on the behavior immediately. When a client is
acting out, the nurse must intervene to stop the behavior, not verbalize feelings of annoyance. Discussing the
client’s feelings can come later, when the client is exhibiting more control.

Which guideline would the nurse consider initially when caring for a client with the
diagnosis of schizophrenia who has hallucinations?
Family members must be included in the plan of care.
The client cannot be distracted from the hallucinations.
The client adamantly believes what is being experienced.
Electroconvulsive therapy should be explained in simple terms.

Rationale
The nurse would consider the guideline that the client adamantly believes what is being experienced. Because
the client believes the hallucinations, initially the nurse would validate the client’s feelings, but not the
experience of the hallucinations, to begin to build trust. Including family members in the plan of care is not
the priority; this may be done later with the client’s permission. Distraction can help clients with schizophrenia
pay less attention to hallucinations, but this is not done initially. Because electroconvulsive therapy usually is
not that effective for schizophrenia, there is no reason to explain its use.

Which behavior would the nurse identify that a client with histrionic personality disorder is
displaying when after being refused a sleeping pill, the client throws a book at the nurse?
 Exploitive
Acting out
Manipulative
Reaction formation

Rationale
The client is acting out. Acting out is the process of expressing feelings behaviorally. The action is not
exploitive, because no evidence is provided to demonstrate that anyone has been used to get what the client
wants. The action is not manipulative, because no evidence is provided to demonstrate that anyone has been
influenced against his or her wishes. The action is not disguising unacceptable feelings by expressing opposite
emotions (reaction formation).

Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the
correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in
one or two of the options . Example: If the item relates to and identifies stroke rehabilitation as its focus and only
one of the options contains the word stroke in relation to rehabilitation, you are safe in identifying this choice as the
correct response.

Which factor would be important when selecting a room for a client with bipolar I disorder
who is hyperactive and talking nonstop in a loud, demanding voice?
A pleasant view

A quiet and restful atmosphere

 Location close to the nurses’ desk

Roommates with similar diagnoses and behaviors

Rationale
The important factor is a quiet and restful atmosphere. During the manic phase of the illness, the client
responds to everything in the environment; therefore, it is important that the room be quiet and restful to
decrease stimulation. A room with a pleasant view is not an important consideration at this time for this
client. A room close to the nurses' desk is too stimulating because of its location. Roommates with similar
diagnoses and behaviors will probably increase both the client’s and the roommate’s acting out.

Which question would the nurse ask to obtain information about a bulimic client’s intake
habits and patterns?
'Are you trying to control other people through the use of food?'

'When you socialize, do you find that you eat more than when you eat by yourself?'
'Do you find yourself eating more right before the beginning of your menstrual cycle?'

'How often are you eating in response to your feelings rather than because you’re hungry?'

Rationale
Clients with bulimia nervosa have a history of eating as a response to strong internal feelings rather than as a
response to the sensation of hunger. Clients with anorexia, not bulimia, often feel powerless and tend to use
restrictive eating as a way to enhance a personal sense of control, not to control others. Clients with bulimia
nervosa usually eat excessive amounts of food when alone rather than with others. They know that their
behavior is dysfunctional and attempt to hide it from others. Binge eating usually is not associated with a
woman’s menstrual cycle.

Which signs and symptoms would the nurse find in a client who is in the depressive phase
of bipolar I disorder? Select all that apply. One, some, or all responses may be correct.
Some correct answers were not selected
Apathy
Hyperactivity

Flight of ideas
Loss of appetite

Sleep disturbances

Rationale
The nurse would find apathy, loss of appetite, and sleep disturbances. When a client is depressed, the mood is
sad or flat, which is manifested by apathy. Depressed people do not have an appetite or the energy to eat.
Difficulty initiating or maintaining sleep or excessive sleepiness is associated with depression. Hyperactivity is
a sign of the manic phase of a bipolar disorder. Flight of ideas is a sign of the manic phase of a bipolar
disorder.
A client who is on long-term corticosteroid therapy after an adrenalectomy is admitted to
the surgical intensive care unit after being involved in a motor vehicle crash. Which
statement is an important concern for client safety?
The dosage of steroids will have to be tapered down slowly to prevent acute adrenal crisis.
Steroid therapy will need to be increased to avert a life-threatening crisis.

Osteoporosis secondary to long-term corticosteroids increases fracture risk.

The client is at risk for Cushing syndrome if taking long-term corticosteroid therapy.

Rationale
Clients with adrenocorticoid insufficiency who are receiving steroid therapy require increased amounts of
medication during periods of stress because they are unable to produce the excess needed by the body. With
severe stress, a failure to ensure adequate corticosteroid levels can be life-threatening. Increased stress
requires an increase, not a decrease, in glucocorticoids. Although osteoporosis may have contributed to
fractures secondary to trauma, this does not present a current risk. Cushing syndrome is a problem with
excess corticosteroid therapy, but after an adrenalectomy, the corticosteroid is given in amounts sufficient to
replace what the body cannot produce.

The nurse is caring for clients who are in the terminal stage of illness. The nurse becomes
aware of feeling depressed when coming to work. Which would the nurse do?
Talk with other nurses on the unit.

Take several personal days off from work.

 Limit emotional involvement with the clients.

Request a transfer to another area of the hospital.

Rationale
Talking with nurses who cope with similar issues allows the nurse to share feelings and obtain constructive
emotional support. Avoidance may provide an immediate solution, but it works only for a short time. The
nurse will eventually have to work through feelings. Limiting emotional involvement with the clients avoids
personal feelings about death and dying and is an unacceptable attitude when caring for dying clients.
Emotional withdrawal may be perceived by the clients as rejection. The nurse will eventually have to work
through feelings.

Which factor is the most significant one that influences a client to cope with an unexpected
hospitalization?
Cognitive age

Past coping styles

Financial resources

General physical health

Rationale
Lifelong coping styles are most important in how a person will deal with stress. Age may influence defense
mechanisms, but lifelong coping styles will most significantly affect a person’s behavior. Financial resources
and general physical health are factors to be considered, but past coping ability is the most significant factor
to predict future coping.

The nurse finds that an older adult has a new onset of decreased consciousness, fatigue,
and hallucinations. Which condition would the nurse suspect in the client?
Delirium
Dementia

Depression
Alzheimer disease

Rationale
Delirium is an acute confusion state in which the client has reduced or disturbed consciousness, fatigue, and
distorted perceptions accompanied by delusions, hallucinations, and misperceptions. Clear consciousness
exists and misconceptions are usually absent in clients with dementia. Clear consciousness exists and
distortions and hallucinations are observed only in severe cases of depression. Alzheimer disease is a
progressive cerebral deterioration that can occur in middle-aged or advanced age adults.

Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is
really asking; look for key words. (2) Read each answer thoroughly and see if it completely covers the material
asked by the question. (3) Narrow the choices by immediately eliminating answers you know are incorrect.
Which statement would the nurse use when informing a client of sexual impairment
associated with bipolar disorder? Select all that apply. One, some, or all responses may be
correct.
'Erectile dysfunction is common.'

'You may have an increased libido.'

'You may experience vaginal dryness.'

'Some clients with bipolar disorder have difficulty achieving orgasm.'

'If you experience pelvic pain, notify your health care provider.'

'Bizarre sexual fantasies can cause some clients to be alarmed.'

Rationale
Increased libido can occur during the manic phase of bipolar disorder. Erectile dysfunction, vaginal dryness,
anorgasmia, genito-pelvic pain, and bizarre sexual fantasies do not occur with bipolar disorder. Erectile
dysfunction can occur with depression and generalized anxiety disorder. Vaginal dryness can occur with
endocrine disorders. Anorgasmia may occur with generalized anxiety disorder. Genito-pelvic pain can occur
with imperforate hymen, vaginitis, and infections. Bizarre sexual fantasies may occur in clients with
schizophrenia.

A client begins escitalopram for treatment of a depressive episode. On the fifth day, the
client refuses the medication, stating, 'It doesn’t help, so what’s the use of taking it?' Which
is the best response by the nurse?
 'It can take 1 to 4 weeks to see an improvement.'

'It takes 6 to 8 weeks for this medication to have an effect.'

'I’ll talk to your primary health care provider about increasing the dosage. That may help.'

'You should have felt a difference by now. I’ll notify the primary health care provider.'

Rationale
It usually takes 1 to 4 weeks to attain a therapeutic blood level of escitalopram. Waiting 6 to 8 weeks is too
long. The client needs more time, not an increased dosage, to see an effect of the medication. There is no
need for the nurse to notify the primary health care provider yet.

Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are
important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a
wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer
with care.

Which intervention would the nurse use when a newly admitted disturbed client refuses to
attend group therapy?
Tell the client that attendance is required.

Insist that the client join for socialization.

Accept the client's decision without discussion.

Have another client ask the client to reconsider.

Rationale
For a newly admitted client, refusal could be an expected response, so accepting the client's decision without
discussion is all the staff can do until trust is established. Requiring or insisting that the client join may result
in a nonproductive confrontation. Clients are not responsible for asking other clients to participate.

Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be
clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices
by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a 4-
option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall
often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago
had seemed completely forgotten.

Which emotion is an older female client most likely to experience immediately after the
sudden death of her husband?
Anger at her husband

Fear of financial problems

Loneliness during holidays

Estrangement from others

Rationale
After a sudden death, anger toward the deceased may occur, because the survivor feels abandoned. Financial
security, loneliness, and estrangement may be problems that the survivor will have to cope with later, but
these are not immediate issues.

Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an educated guess on
your part, go ahead and mark an answer. You might be right, but if you leave it blank, you will certainly be
wrong and lose precious points.

Which intervention would the nurse use after finding a disturbed client in bed in the fetal
position?
Sit down in a chair by the client and say, 'I'm here to spend time with you.'
Touch the client gently on the shoulder and say, 'I'm going to sit with you for a while.'

Say to the client, 'I'll be waiting for you in the community room, so please get up and join me.'
Leave the client alone because the client won’t benefit from talking with the nurse.

Rationale
'I'm here to spend time with you,' shows acceptance of the client at the current level and allows the client to set
the pace of the relationship. Touching the client may be misinterpreted and may precipitate an aggressive
response. This client is not able to join the nurse in the community room; in the therapeutic relationship, the
nurse must reach out to the client. Even if the client is too withdrawn to respond, the nurse's physical
presence can be reassuring.

A terminally ill client is continuously angry, but the nurse has been encouraging the client
to make decisions about daily activities. Which client statement indicates that some of the
anger may have resolved?
'Leave me alone! I want to do it myself. Anyway, you’re too busy to help me.'

'You've got a busy morning ahead of you! I'm really a mess. Hurry up, let’s do this.'

'I can do my face, hands, arms, and chest today, but I think you'd better do the rest.'
'It's so hard to let someone do so much for me. I don't like it when others do things for me.'

Rationale
Allowing the nurse to take care of some of the responsibility demonstrates the client's diminished anger and is
a realistic assessment and acceptance of current capabilities and limitations. Anger is still apparent when the
client tells the nurse to leave him or her alone. 'You’ve got a busy morning,' shifts all of the responsibility back
to the nurse; the client either has given up or is being sarcastic. 'I don’t like it,' suggests that the client is still
angry.

During the working phase of the nurse –client relationship, which question would the nurse
ask the depressed client who has a history of suicide attempts when exploring alternative
coping strategies?
'How have you managed your problems in the past?'
'What do you feel that you’ve learned from this suicide attempt?'

'How will you manage the next time your problems start piling up?'
'Were there other things going on in your life that made you want to die?'
Rationale
The nurse would ask, 'How will you manage the next time your problems start piling up?' because this focuses
the interaction toward the future and invites the client to explore alternative coping strategies. 'How have you
managed your problems in the past?' explores past coping strategies and should have been asked as a part of
the initial assessment. 'What do you feel that you’ve learned from this suicide attempt?' is an attempt to
explore the client’s insight into current feelings about the suicide rather than focusing on coping strategies.
'Were there other things going on in your life that made you want to die?' asks the client once more to ensure
that all the precipitating stressors have been identified but does not focus on future coping strategies.

Which response would the nurse make to a depressed client who says, 'I’m stupid and
useless. Talk with the other people who are more important'?
'Everyone is important.'

'Do you feel that you’re not important?'

'Why do you feel that you’re not important?'

'I want to talk with you because you are important to me.'

Rationale
The response, 'I want to talk with you because you are important to me,' is an expression of the nurse’s
positive thoughts about the client and lets the client know that the nurse is accepting of the client. 'Everyone
is important,' demonstrates the nurse’s positive thoughts about all people and does not focus on the client
specifically. 'Do you feel that you are not important?' is a closed-ended question and may not promote
verbalization of feelings. The client may not be aware of what has caused the feelings of insignificance and
may not be able to answer the question, 'Why do you feel that you’re not important?' The use of the word 'why'
should be avoided.

Which parameter would the nurse assess for in a client with borderline personality disorder
and possible depression who has a history of self-abusive, acting-out behavior?
Degree of anger
Potential for suicide

Level of intelligence
Ability to test reality

Rationale
The nurse would assess the potential for suicide in this client who has self-abusive, acting-out behavior.
Depressed clients may use suicide as the ultimate escape from feelings; ensuring safety by protecting the
client from self-harm is the priority. Although degree of anger is important to assess, anger indicates the
depression has turned outward, not inward for possible suicide. Assessment of the level of intelligence is
unnecessary; clients with a diagnosis of borderline personality disorder are usually of average intelligence.
Clients with a diagnosis of borderline personality disorder are more concerned with satisfying their needs
than testing reality; they are more concerned about themselves than others or the environment.

Which conclusion would the nurse make about a client who confides, 'I’ve been thinking
about suicide lately'?
This statement is intended to frighten the nurse.
 The client wants attention from the staff.

This statement indicates a feeling of safety with the nurse.

The client is seeking protection from the impulses/thoughts.

Rationale
The client is seeking protection from the impulses/thoughts. Clients often report suicidal feelings so the staff
will have the chance to stop them. When clients relay messages of suicide to the nurse, it is not to frighten the
nurse. Speaking about suicide to the nurse is a cry for help, not a cry for attention. Although the client may
feel safe with the nurse, this is not the conclusion the nurse would make. The client is seeking help.

Which information would the nurse include in client teaching regarding electroconvulsive
therapy (ECT)?
The treatment will not cause pain because you will receive anesthesia.
The treatment is totally safe with the new methods of administration.

You may ask any question, but it is better not to talk about the therapy.
You may experience unrecoverable short-term and long-term memory loss.

Rationale
Client education would include how the treatment will not cause pain because of the anesthesia received.
Clients fear ECT because they think it will be painful. If they are reassured that they will be asleep and will feel
no pain, there will be less anxiety. No treatment that requires anesthesia is totally safe. Clients may not realize
their own fears and therefore may not know what questions to ask; also, this response cuts off further
communication and is not therapeutic. Temporary, not permanent, memory loss occurs.

Which action would the nurse take when caring for a client with a conversion disorder who
has paralysis in the lower legs?
Discuss topics other than the paralysis.

Explain the reason for the physical problem.

Ask how the client feels about being paralyzed.

Encourage the client to slowly walk around the room.

Rationale
The nurse would discuss topics other than the paralysis. Discussion of signs and symptoms would not be
initiated by the nurse; the signs and symptoms would be accepted by the nurse. Discussion would be focused
on the client’s feelings and current situation. Explaining the reason for the physical problem may take away
the client’s unconscious defense and increase anxiety. Asking how the client feels about being paralyzed
focuses on the paralysis rather than feelings. Encouraging the client to slowly walk around the room denies
the client’s symptoms; in reality this client cannot make the legs move to walk.

Which response would the nurse make to a client who overdosed on sedatives and says, 'Let
me die. I’m no good'?
'Tell me why you did this.'
 'You must have been upset to try to take your life.'
'Of course you’re good; we’ll take excellent care of you.'

'You’ve been through a rough time; let me take care of you.'

Rationale
The nurse would respond by saying, 'You must have been upset to try to take your life.' Identifying and
showing understanding of the client’s feelings by giving feedback help establish a therapeutic relationship and
promote exploration of feelings. Asking why the client attempted suicide is too direct and confrontational; it
does not allow the client time to reflect and explore feelings. Saying the client is good and promising to take
care of the client negates the client’s feelings and cuts off any further communication of feelings. Although
saying, 'You’ve been through a rough time' is appropriate, saying 'Let me take care of you' encourages
dependence; it does not permit exploration of feelings.

As a group leader for depressed clients, which primary concern would the nurse be
prepared to manage when it is learned that a client hid suicidal urges and died by suicide
several days ago?
Remorse of the staff for failing to anticipate and prevent the suicide

Guilt of group members because they could not prevent another’s suicide
Lack of concern over the suicide expressed by several of the members in the group

Fear by some members that their own suicidal urges may go unnoticed and that they may go
unprotected
Rationale
The nurse would be prepared to manage the fear some members may have that their own suicidal urges may
go unnoticed and that they may go unprotected. Ambivalence about life and death, plus the introspection
commonly found in clients with emotional problems, can lead to increased anxiety and fear among the group
members. Possible feelings of remorse of the staff must be handled within the support and supervisory
systems for the staff, not within the client group therapy sessions; the group members are the primary
concern. Guilt that the group’s members might feel because they could not prevent another’s suicide will
probably be a secondary concern of the group leader. Lack of concern over the suicide expressed by several of
the members in the group is not a primary concern, but this should be explored later to determine the reason
for such apparent indifference, which may be a mask to cover true feelings.

Which response would the nurse make to a depressed client who is still in bed and says, 'I
can’t get dressed and go to breakfast'?
'You can’t just lie in bed. You need to get up now and go to breakfast.'
'I’ll get you dressed. I understand that you have difficulty helping yourself.'

'Promise me you’ll get dressed for lunch. If you do, I’ll let you stay here in bed.'
'Take your time. It is not necessary to hurry, and I’ll help you if you need me to.'

Rationale
The nurse would say, 'Take your time. It is not necessary to hurry, and I’ll help you if you need me to.' Telling
the client, 'Take your time,' and offering to help recognizes the client’s capability without adding stress or
increasing dependency. Telling the client to get up does not address the client’s needs and is judgmental.
Offering to get the client dressed will increase dependency, which is not therapeutic. Asking the client to
promise to get dressed for lunch if allowed to stay in bed at breakfast is an attempt to manipulate compliance;
the client cannot accept responsibility for the future.

Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be
clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices
by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a
four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall
often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago
had seemed completely forgotten.

To help a client with bipolar disorder who is aggressive and disruptive in group and social
settings develop social skills, which initial approach would the nurse take?
Facilitating one-on-one interactions
Encouraging self-care with support

Developing guidelines for behavior

Helping the client decrease activity level

Rationale
The nurse would facilitate one-on-one interactions. The client who is aggressive in groups must begin
socialization in one-on-one interactions that are less stimulating and distracting. Promoting self-care avoids
addressing behaviors in group and social situations. The client may not be interested in or able to develop
guidelines for appropriate behavior at this time. The client may not be able to decrease activity at this time,
and it must be channeled appropriately.

Which symptoms would the nurse include when teaching a client to recognize symptoms of
hypoglycemia? Select all that apply. One, some, or all responses may be correct.
Rapid heartbeat

Emotional changes
Abdominal cramping

Nausea and vomiting

Weakness and fatigue

Numbness of fingers, toes, or mouth

Rationale
A rapid heartbeat, emotional changes, and numbness of the fingers, toes, or mouth are all signs of
hypoglycemia. Abdominal cramping, nausea and vomiting, and weakness and fatigue are indicative of
hyperglycemia.

Correct
(205)

Which assessment finding would the nurse observe in a client with bipolar disorder, manic
phase?
Constant singing

Ritualistic behavior
Flat affect

Apathetic demeanor

Rationale
Constant singing would be typical in a client with bipolar disorder, manic phase. Ritualistic behavior is
indicative of obsessive-compulsive disorder. A flat affect and apathetic demeanor are more indicative of a
schizophrenic or depressive disorder.

Which action would the nurse take to help a female, bipolar client in the manic episode
meet personal hygiene needs?
Suggest that she wear hospital clothing.
Guide her to dress appropriately in her own clothing.

Allow her to apply makeup in whatever manner she chooses.

Keep makeup away from her because she will apply it too freely.

Rationale
The nurse would guide the client to dress appropriately in her own clothing. Having clients who are
experiencing a manic episode of bipolar disorder wear personal clothing helps keep them more in touch with
reality. The client may need direction to dress appropriately. Suggesting that she wear hospital clothing does
not help the client learn to follow the therapeutic milieu. Allowing her to apply makeup in whatever manner
she chooses may set up the client as a target of ridicule by other clients. The client may use makeup but with
supervision.

Test-Taking Tip: What happens if you find yourself in a slump over the examination? Take a time-out to
refocus and reenergize! Talk to friends and family who support your efforts in achieving one of your major
accomplishments in life. This effort will help you regain confidence in yourself and get you back on track
toward the realization of your long-anticipated goal.

Fluoxetine is prescribed for a client with depression. Which precaution will the nurse
consider when initiating treatment with this medication?
It must be given with milk and crackers to prevent hyperacidity and discomfort.
Eating cheese or pickled herring or drinking wine may cause a hypertensive crisis.

The blood level may not be sufficient to cause noticeable improvement for 2 to 4 weeks.
The blood level should be checked weekly for 3 months to make sure it is appropriate.

Rationale
Fluoxetine does not produce an immediate effect; nursing measures must be continued to reduce the risk for
suicide. Consuming milk and crackers to help prevent hyperacidity and discomfort is not necessary. Avoiding
cheese, pickled herring, and wine is a precaution taken with monoamine oxidase inhibitors. Weekly blood level
checks are not necessary with fluoxetine.

Which characteristic can be observed in abusive parents? Select all that apply. One, some,
or all responses may be correct.
Social isolation
Poor coping skills

Family authoritarianism
Feeling of no control over life

Inability to seek help from others

Expects child to satisfy needs for love

Rationale
Social isolation, poor coping skills, family authoritarianism, feeling of no control over life, inability to seek help
from others, and expecting the child to satisfy needs for love, support, and reassurance are all characteristics
of abusive parents.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked
to select all options that apply to a given situation or client. All options likely relate to the situation, but only
some of the options may relate directly to the situation.
The nurse is teaching a client about tricyclic antidepressants. Which potential side effects
would the nurse include? Select all that apply. One, some, or all responses may be correct.
Dry mouth
Drowsiness

Constipation
Severe hypertension

Orthostatic hypotension

Rationale
Dry mouth is a common anticholinergic side effect of tricyclic antidepressants. Drowsiness can be a common
side effect but usually decreases with continued treatment. Constipation is a common side effect that usually
can be managed with stool softeners and a high-fiber diet. Orthostatic hypotension is a common side effect of
tricyclic antidepressants; the client should be instructed to rise slowly from a sitting to a standing position.
Hypertension of any type is not a side effect of tricyclic antidepressants.

Which term would the nurse use to describe a female client who states that she no longer
enjoys any of the activities that she once found fun and pleasurable?
Anergia

Anhedonia
Grandiosity
 Tangentiality

Rationale
The term to use is anhedonia. Anhedonia is the inability to experience pleasure in events or activities that once
were enjoyable. Anergia is lethargy and a decreased level of energy. Grandiosity is a symptom seen during
manic episodes in which an individual displays an inflated self-esteem. Tangentiality is speaking about
subjects unrelated or tangent to the main discussion topic or responding to questions without answering the
question.

Test-Taking Tip: Being emotionally prepared for an examination is key to your success. Proper use of
resources over an extended period of time ensures your understanding and increases your confidence about
your nursing knowledge. Your lifelong dream of becoming a nurse is now within your reach! You are excited,
yet anxious. This feeling is normal. A little anxiety can be good because it increases awareness of reality; but
excessive anxiety has the opposite effect, acting as a barrier and keeping you from reaching your goal. Your
attitude about yourself and your goals will help keep you focused, adding to your strength and inner
conviction to achieve success.

Which statements meet the criteria for involuntary hospitalization? Select all that apply.
One, some, or all responses may be correct.
'I cry all the time; I'm just so sad.'
'Since I retired I've been so depressed.'

'I'd like to end it all with sleeping pills.'

 'The voices say I should kill all prostitutes.'
'My boss makes me so angry—he's always picking on me.'

Rationale
The suicide threat 'end it all' is a direct expression of intent without action. Likewise, the potential threat to
harm others indicates the need for admission. Confiding feelings of sadness, depression, or anger without
intent for self-harm or harm others does not meet the criteria.

Which prescribed treatment would a nurse anticipate for a client with severe, persistent,
intractable depression and suicidal ideation?
Electroconvulsive therapy

Short-term psychoanalysis
Nondirective psychotherapy

High doses of anxiolytic medications

Rationale
The nurse would anticipate electroconvulsive therapy. Electroconvulsive therapy, which interrupts established
patterns of behavior, helps relieve symptoms and limits suicide attempts in clients with severe, intractable
depression that do not respond to antidepressant medication. The client’s depressed mood limits
participation in psychoanalysis, which is usually long term; feelings precipitated by therapy may lead to
suicidal acting out. Psychotherapy should be directed, not nondirective, toward helping the client learn new
coping mechanisms and better ways of coping with problems; the depressed client needs direction to
accomplish this. Nondirective psychotherapy would be ineffective. Antianxiety medications (anxiolytic
medications) are usually not prescribed for clients with depression.

Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize
the right answer when they see it or that the right answer will somehow stand out from the other choices. This
is a dangerous misconception. The more carefully the question is constructed, the more each of the choices
will seem like the correct response.

Which initial action would the nurse take to provide a therapeutic environment for a client
who is withdrawn and reclusive?
Foster a trusting relationship.

Administer medications on time.

Involve the client in a group with peers.

Remove the client from the family home.

Rationale
Initially, the nurse would foster a trusting relationship. An interpersonal relationship based on trust must be
established before a client can be helped. Administering medications on time is an important part of the
treatment and care, but it is of lesser importance than a trusting relationship. Socialization comes at a later
point in therapy. There is nothing to indicate a need to remove the client from the home.
Which action would the nurse take for an adolescent with a long history of drug abuse,
stealing, and refusal to comply with rules?
Provide activities that ensure immediate gratification and social stimulation.

Allow as much freedom as possible, setting few rules and minimal structure.
Serve as a role model for mature behavior while providing a structured setting.

Behave in a punitive manner toward the adolescent when rules are not followed.

Rationale
The nurse would serve as a role model for mature behavior while providing a structured setting. The client is
unable to control impulses at this time, so control must be provided for the client; the nurse’s behavior
provides a role model. Providing activities that ensure immediate gratification and social stimulation will
probably provoke even more acting-out behavior. The client is not able to set self-controls; freedom may prove
overwhelming, resulting in chaos on the unit. Behaving in a punitive manner toward the adolescent when
rules are not followed could provoke even more acting-out behavior and lead to a power struggle between the
nurse and client.

Test-Taking Tip: A psychological technique used to boost your test-taking confidence is to look into a mirror
whenever you pass one and say out loud, 'I know the material, and I'll do well on the test.' Try it; many
students have found that it works because it reduces 'test anxiety.'

Which feeling would the nurse anticipate a manic client with bipolar 1 disorder is likely
experiencing?
 Guilt
Grandeur

Worthlessness
Self-deprecation

Rationale
The nurse would anticipate the client would experience feelings of grandeur. During a manic episode a client
has an inflated self-esteem. Feelings of guilt, worthlessness, and self-deprecation are not associated with
bipolar disorder, manic episode; these occur during the depressive phase.

Which response would the nurse make to a depressed, crying client on the evening of
admission?
'You’re crying. Let’s talk about it.'

'Let me get a cup of coffee; then we can talk.'

'Visitors will be here soon; you’d better get ready.'

'You’ll feel better soon. Come to the sitting room with me.'

Rationale
Noting that the client is crying and suggesting that the nurse and client talk about it addresses the behavior
observed, and the offer by the nurse to spend time to help the client implies that the client is worthy. With 'Let
me get a cup of coffee; then we can talk' the nurse offers to help but places the client second by stating the
desire to get coffee first. The nurse denies the client’s feelings by focusing on getting ready for visitors.
Assuring the client that the client will feel better soon and asking the client to come to the sitting room
constitutes false reassurance, ignores the crying, and blocks communication.

Which action would the nurse take for a client with borderline personality disorder?
Provide an unstructured environment to promote self-expression.

Be firm, consistent, and understanding while focusing on specific target behaviors.

Use an authoritarian approach, because this type of client needs to learn to conform to the rules of
society.
Record but ignore marked shifts in mood, suicidal threats, and temper displays because these are
attention-seeking behaviors.

Rationale
The nurse would be firm, consistent, and understanding while focusing on specific target behaviors.
Consistency, limit-setting, and supportive confrontation are essential nursing interventions designed to
provide a secure, therapeutic environment for clients with borderline personality disorder. To be therapeutic,
the environment needs structure, and the staff must help the client set short-term goals for behavioral
changes. The use of an authoritarian approach will increase anxiety in this type of client, resulting in feelings
of rejection and withdrawal. Ignoring the client’s behavior is nontherapeutic and may reinforce underlying
fears of abandonment.
Which intervention would provide the greatest safety for a client admitted to a mental
health unit because of suicidal ideation?
Seclusion room

Four-point restraints
Continual one-on-one supervision

Removal of unsafe objects from the environment

Rationale
The intervention that would provide the greatest safety is continual one-on-one supervision. A member of the
health team provides a continuous presence to ensure the safety of a client who is at high risk for suicide.
Seclusion and four-point restraints are overly restrictive. Although removing unsafe objects from the
environment is important, clients who are intent on self-harm will find ways even if such objects are removed.

Test-Taking Tip: When using this program, be sure to note if you guess at an answer. This will permit you to
identify areas that need further review. Also, it will help you see how correct your guessing can be.

To further assess a client’s suicidal potential, the nurse would be especially alert to the
client’s expression of which emotions?
Anger and resentment
Loneliness and anxiety

Frustration and fear of death

 Helplessness and hopelessness

Rationale
The nurse would assess for helplessness and hopelessness. The expression of helplessness and hopelessness
may indicate that this client is unable to continue the struggle of life. Anger and resentment are not
indications of potential suicide; the client is still responding to the world, not attempting to leave it.
Loneliness and anxiety are usually not sufficient to precipitate a suicide attempt. The client attempting suicide
usually sees death as a release and does not fear death. Frustration indicates the client is responding to
experiences and emotions.

In which type of room would the nurse tell the admissions clerk to place a client with
bipolar I disorder, manic phase?
Private

Isolation
Semi-private

Negative-airflow

Rationale
The nurse would assign the manic client to a private room. The client who is manic needs a nonstimulating
environment. A person who is bipolar is not contagious and does not require an isolation room. The presence
of another person in the room is considered stimulating and may interfere with the rest and sleep of both
clients. A client who is bipolar does not need a negative-airflow room. This type of room is appropriate for a
client with a communicable disease, such as tuberculosis, that requires airborne precautions.

Test-Taking Tip: Notice how the subjects of the questions are related and, through that relationship, the
answers to some of the questions may be provided within other questions of the test.

Which action would the nurse take for a client with major depression who is tearful and
refuses to eat dinner after a visit with a friend?
Allow the client to skip the meal.
Offer an opportunity to discuss the visit.

Reinforce the importance of adequate nutrition.

Provide the client with adequate quiet thinking time.

Rationale
The nurse would offer an opportunity to discuss the visit. Offering to discuss the visit shows support and
provides the client with an opportunity to discuss feelings. Allowing the client to skip dinner does not address
the client’s depression. Teaching about the importance of adequate nutrition is inappropriate when a client is
emotionally distressed. Providing quiet thinking time will limit further communication and may imply
rejection.

Test-Taking Tip: Do not read too much into the question or worry that it is a 'trick.' If you have nursing
experience, ask yourself how a classmate who is inexperienced would answer this question from only the
information provided in the textbooks or given in the lectures.

Which response would the nurse make to a client who has been attending a day treatment
facility for 1 month with depressive disorder and is to be discharged in a week?
'We have just a few sessions left. I’m really pleased at your progress.'

'Your discharge date has been set for next week. That’s wonderful news.'
'There are five sessions remaining. We need to start making plans to end our sessions.'

'I understand that your discharge is set for next week. I’m wondering how you feel about that?'

Rationale
The nurse would say, 'I understand that your discharge is set for next week. I’m wondering how you feel about
that?' Plans for termination that take emotional needs into account are best made after exploration of the
client’s thoughts and feelings about discharge. Noting that there are just a few sessions left and expressing
pleasure at the client’s progress acknowledges the future termination but focuses on the nurse’s, not the
client’s, feelings. Noting that the client’s discharge date has been set for next week and calling this wonderful
news acknowledges the future termination but suggests that the client should feel wonderful about the
discharge, which may or may not be true. Although noting that the client and nurse have five sessions
remaining and that they need to start making plans to end the sessions acknowledges the future termination,
plans for termination should be made after a discussion of the client’s emotional response to the pending
discharge.
Which disorder would the nurse classify as neurodevelopmental?
Anxiety
Bipolar disorder

Schizophreniform disorder
Attention-deficit/hyperactivity disorder

Rationale
Neurodevelopmental disorders are a group of conditions with onset in the developmental period. Attention-
deficit/hyperactivity disorder is a neurodevelopmental disorder. Anxiety, bipolar disorder, and
schizophreniform disorder are not classified as neurodevelopmental.

Test-Taking Tip: Come to your test prep with a positive attitude about yourself, your nursing knowledge, and
your test-taking abilities. A positive attitude is achieved through self-confidence gained by effective study. This
means (a) answering questions (assessment), (b) organizing study time (planning), (c) reading and further
study (implementation), and (d) answering questions (evaluation).

Which personality disorder would the nurse suspect in a client telling a rambling, lengthy,
unclear, and overly detailed story about their dog, who they say is the president? Select all
that apply. One, some, or all responses may be correct.
Schizoid

Paranoid
 Histrionic
Borderline

Narcissistic
Schizotypal

Rationale
People with schizotypal personality disorder demonstrate symptoms that are strikingly strange and unusual,
such as magical thinking, odd beliefs, strange speech patterns, and inappropriate affect. A client telling an odd
and rambling story about their dog being the president would be demonstrating behavior consistent with
schizotypal personality disorder. People with schizoid personality disorder display a lack of interest in social
relationships. Paranoid personality disorder is characterized by a longstanding distrust and suspicion of others
based on the belief (unsupported by evidence) that others want to exploit, harm, or deceive the person. People
with histrionic personality disorder are excitable and dramatic yet often high functioning. Borderline
personality disorder is characterized by severe impairments in functioning caused by patterns of marked
instability in emotional control or regulation, impulsivity, identity or self-image distortions, unstable mood,
and unstable interpersonal relationships. Narcissistic personality disorder is characterized by feelings of
entitlement, an exaggerated belief in one’s own importance, and a lack of empathy.

While caring for an older adult client, which symptom would require an immediate
reassessment of the client’s needs and plan of care?
Memory loss or confusion

Neglect of self-care
 Increased daily fatigue

Withdrawal from usual activities

Rationale
Memory loss or confusion would require an immediate reassessment. All are common signs of depression
due to the aging process; however, memory loss or confusion requires immediate intervention. The
development of confusion indicates that the client’s ability to maintain equilibrium has not been achieved and
that further disequilibrium is occurring, setting the client up for safety issues. Confusion may also be related
to more serious physical conditions that can occur which require medical intervention. Although neglect of
self-care can occur, it is not the immediate need. Although increased daily fatigue is important, it does not
require immediate follow-up. It is common for clients with depression to withdraw from usual activities, so it
does not need immediate reassessment.

A 70-year-old man with a history of depression has few interests since retirement. He says,
'I feel useless and unneeded.' Based on Erikson’s psychosocial stages of development, which
outcome is occurring?
Guilt
Despair

Isolation
Role confusion
Rationale
Integrity versus despair is the task of the older adult; the client has difficulty accepting what life is and was,
resulting in feelings of despair and disgust. Initiative versus guilt is the task of the preschool-aged child.
Intimacy versus isolation is the task of the young adult. Identity versus role confusion is the task of the
adolescent.

Which term would be used to document the client’s affect, which was observed during the
mental status assessment?
Depressed

Flat
Cooperative

Resistive

Rationale
Affect is the observable outward manifestation of a person's mood, feelings, or tone. Common terms to
describe affect include inappropriate, flat, or blunted. Mood is a feeling state reported by the client (e.g., sad,
depressed, angry, anxious, happy). Attitude relates to the approach or manner of the client during the
interaction with the interviewer (e.g., cooperative, resistive, friendly, ingratiating).

A client in the mental health unit is walking swiftly around the room and rubbing his hands
together. Which term describes the behavior?
 Tardive dyskinesia
Withdrawal syndrome

Psychomotor agitation
Psychophysiological insomnia

Rationale
Psychomotor agitation is constant motion such as pacing, hand wringing, nail biting, and other types of
energetic body movements. Tardive dyskinesia is a syndrome of involuntary movements (e.g., oral, buccal,
lingual, masticatory) that occur as a result of prolonged treatment with neuroleptic medications that block
dopamine type 2 receptors. Withdrawal syndrome includes the signs and symptoms caused by the abrupt
cessation of a substance that the client has become dependent on as a result of prolonged use.
Psychophysiological insomnia refers to difficulty attaining or maintaining sleep; it is not related to agitated
behavior.

Which response would the nurse make to a depressed client who asks, 'Do you think they’ll
ever let me out of here'?
'We should ask your primary health care provider.'
'Everyone says you’re doing fine.'

'Do you think you’re ready to leave?'

'How do you feel about leaving here?'
Rationale
The nurse would ask, 'How do you feel about leaving here?' The nurse’s response asking about the client’s
feelings about leaving urges the client to reflect on feelings and encourages communication. Saying, 'We
should ask your primary health care provider,' shifts responsibility from the nurse to the primary health care
provider; it is an evasive response. Responding, 'Everyone says you’re doing fine,' does not address what the
client is asking the nurse; it closes the door to further communication and the nurse cannot speak for others.
Asking, 'Do you think you’re ready to leave?' may elicit a yes or no answer; it does not encourage
communication because it is a closed-ended question.

STUDY TIP: Enhance your organizational skills by developing a checklist and creating ways to improve your
ability to retain information, such as using index cards with essential data, which are easy to carry and review
whenever you have a spare moment.

Which response would the nurse make to a hyperactive client who demands to be allowed
to go downtown to shop and does not currently have privileges?
'You can’t leave the unit, because you’re too sick.'

'You’ll have to ask your primary health care provider for permission to go.'
'You’ll have to wait, because no staff member is available to go with you.'

'You don’t have privileges to leave, but we can look through this new catalog.'

Rationale
The nurse would say, 'You don’t have privileges to leave, but we can look through this new catalog.' Clients
who are hyperactive are easily diverted. It is best to use distraction rather than precipitate a confrontation.
Telling the client that leaving will not be allowed ignores the client’s wishes and offers no alternative behavior.
Telling the client that the primary health care provider will have to be called shifts responsibility to the primary
health care provider; the nurse would know that a shopping trip is unrealistic at this time. Telling the client
that no one is available to accompany the client only postpones the need to address the problem.

On the day after admission, which response would the nurse make to a suicidal client who
asks, 'Why am I being watched around the clock, and why can’t I walk around the whole
unit?'
'Why do you think we’re observing you?'

'What makes you think we’re observing you?'

'We’re concerned that you might try to harm yourself.'

'We’re following orders, so there must be a reason.'

Rationale
The statement 'We’re concerned that you might try to harm yourself' is honest and helps establish trust. Also,
it may help the client realize that the staff members care. 'Why do you think we’re observing you?' will put the
client on the defensive, and asking 'why' should be avoided. 'What makes you think we’re observing you?' is an
inappropriate response when the answer is so obvious. The response 'We’re following orders, so there must be
a reason' is evasive.
Which guideline would the nurse consider when caring for clients who are at risk for
suicide?
A client who fails in a suicide attempt will probably not try again.
Formal suicide plans increase the likelihood that a client will attempt suicide.

It is best not to talk to clients about suicide, because it may give them the idea.
Clients who talk about suicide are not planning it; they are using the threat to gain attention.

Rationale
The nurse would consider the following guideline: Formal suicide plans increase the likelihood that a client
will attempt suicide. A formal plan demonstrates determination, concentration, and effort, with conclusions
already thought out. Failure to successfully complete the suicidal act can add to feelings of worthlessness and
stimulate further acts. Verbalizing feelings may help reduce the client’s need to act out. Many clients verbalize
their suicidal thoughts as they are working on their decision and plan of action; a suicide attempt is not
necessarily just to receive attention; it is a cry for help.

Which response would the nurse make to a client who refuses to get out of bed and says,
'I’m too sick to be helped and I don’t want to be bothered'?
'You won’t feel better unless you make the effort to get up and get dressed.'
'You’ll feel better again if you just make an attempt to help yourself.'

'Everyone feels this way in the beginning as they confront their feelings.'
 'I know you don’t feel like getting up, but let me help you get started.'

Rationale
The nurse would say, 'I know you don’t feel like getting up, let me help you get started.' This statement
acknowledges the client’s feelings, offers hope, and helps the client to a higher level of function. The
statement, 'You won’t feel better unless you make the effort to get up and get dressed,' ignores the client’s
feelings and may not be true. The statement, 'You’ll feel better again if you just make an attempt to help
yourself,' denies the client’s feelings and feeling better cannot be guaranteed. The statement, 'Everyone feels
this way in the beginning as they confront their feelings,' minimizes the client’s feelings; also, the client is not
interested in how others feel.

Which response would the nurse make to the husband who told his suicidal wife that he
would bring their 26-month-old daughter to visit and asks if that would be possible. Which
is the best response by the nurse?
'Probably so, but you’d better check with her primary health care provider first.'
'Of course! Children of all ages are welcome to visit relatives.'

'It could be very upsetting for your child to see her mother so depressed.'
'Tell me what your wife said when you offered to bring your child for a visit.'

Rationale
The nurse would determine whether the spouse has discussed the child visiting with the client before
commenting further. The responses, 'Probably so, but you’d better check with her primary health care provider
first,' and 'Of course! Children of all ages are welcome to visit relatives,' assume that the client has consented
to the visit; this assumption may be incorrect. The response, 'It may be very upsetting for your child to see her
mother so depressed,' makes an assumption that requires more data and discussion to validate.

Which B vitamin deficiency will result in Wernicke encephalopathy?

B 3 (niacin)

B 1 (thiamine)
B 2 (riboflavin)

B 6 (pyridoxine)

Rationale
Severe deficiency of thiamine will result in Wernicke encephalopathy. Niacin deficiency causes pellagra.
Riboflavin deficiency can result in cutaneous, oral, and corneal changes. Pyridoxine deficiency can progress to
sideroblastic anemia, neurological disturbances, and xanthurenic aciduria, among other problems.

Which suicide method would indicate a low threat of lethality?

Hanging
Ingesting pills

Jumping from a tall bridge

 Poisoning with carbon monoxide

Rationale
Ingesting pills is considered the least lethal of these suicide methods, because it is considered slower.
Hanging, jumping, and carbon monoxide poisoning are all quicker and therefore more lethal methods.

Which legal ramification would be indicated when a newly admitted male client with bipolar
disorder who has a history of hyperactivity and combativeness is found later in the evening
beating another client?
The client should have been placed in restraints on admission.
Keeping the client sedated is necessary for a client who is known to have been combative.

A client with bipolar disorder who is in contact with reality does not require supervision.
Because it was known that the client was frequently combative, close observation by the nursing staff
was indicated.

Rationale
The legal ramification is such that, because it was known that the client was frequently combative, close
observation by the nursing staff was indicated. The nurse, knowing that the client has been combative, was
negligent in not providing close supervision; a reasonable, prudent nurse would have observed the client
closely to protect against self-imposed injury and to protect others. A client may be placed in restraints only
because of current unsafe behaviors, not because of past history and not because of admission. It is unrealistic
to keep a client sedated because of a past history of combativeness; this is termed chemical restraints. All
clients should be supervised, especially those who have a history of combativeness and who are newly
admitted.

Which documentation entry would the nurse chart for a client with a mood disorder who
says, 'I feel rotten. I feel useless. I can’t think straight. I feel overwhelmed by everything. I
don’t know if I can go on'?
The client said, 'I can’t think straight,' and is not able to cope with current problems.
The client appears to be very depressed for most of the morning and has little interest in self or the
environment.
The client expressed suicidal thoughts about not being able to go on and exhibits diminished ability
to think clearly.
The client stated, 'I feel rotten. I feel useless. I can’t think straight. I feel overwhelmed by everything. I
don’t know if I can go on.'

Rationale
The nurse would chart that the client stated, 'I feel rotten. I feel useless. I can’t think straight. I feel
overwhelmed by everything. I don’t know if I can go on.' Directly quoting the client, with no added value
judgments, is an objective documentation of what happened. Writing down part of what the client said ('I can’t
think straight') and then concluding that the client can’t cope reflects a subjective judgment and an
interpretation of what the client actually said. Noting that the client appeared very depressed for most of the
morning and showed little interest in self or the environment is a subjective judgment and an interpretation
of what the client actually said. Documenting that the client expressed suicidal thoughts about not being able
to go on and has a decreased ability to think clearly is a subjective judgment and an interpretation of what the
client actually said.

Test-Taking Tip: As you answer each question, write a few words about why you think that answer is correct; in
other words, justify why you selected that answer. If an answer you provide is a guess, mark the question to
identify it. This will permit you to recognize areas that need further review. It will also help you see how correct
your 'guessing' can be. Remember: on the licensure examination you must answer each question before
moving on to the next question.

Which action would be difficult for a client who has borderline personality disorder to
complete during the orientation phase of a therapeutic relationship?
Controlling anxiety
Terminating the session on time

Accepting the psychiatric diagnosis

Setting mutual goals for the relationship

Rationale
Setting mutual goals for the relationship would be difficult for clients with borderline personality disorder
during the orientation phase. Clients with borderline personality disorder often demonstrate a pattern of
unstable interpersonal relationships, impulsiveness, affective instability, and frantic efforts to avoid
abandonment; these behaviors usually create great difficulty in establishing mutual goals. Controlling anxiety
would not be difficult until the client is in the working phase of the relationship. Terminating the session on
time would be difficult in the termination phase of the relationship. During the orientation phase of the
relationship, accepting the psychiatric diagnosis would not be the issue.

A client with type 1 diabetes receives 30 units of neutral protamine Hagedorn (NPH) insulin
at 7:00 AM. At 3:30 PM, the client becomes diaphoretic, weak, and pale. With which
condition would the nurse determine that these physiological responses are associated?
Diabetic coma
Hyperosmolar hyperglycemic nonketotic syndrome

Diabetic ketoacidosis
Hypoglycemic reaction

Rationale
These are sympathetic nervous system responses to hypoglycemia; the peak action of NPH insulin is 8 to 12
hours after administration, and 8.5 hours have elapsed since it was given. The signs and symptoms of diabetic
coma are dry mucous membranes; hot, flushed skin; deep, rapid respirations (Kussmaul breathing); acetone
odor to the breath; nausea and vomiting; and, as with hypoglycemia, weakness. Hyperosmolar hyperglycemic
nonketotic syndrome (HHNS) is a hyperglycemic state and this client has symptoms of a hypoglycemic state.
Ketoacidosis results from excess use of fats for energy when carbohydrates cannot be used. Lipids are
metabolized incompletely, and dehydration, acidosis (both ketotic and lactic), and electrolyte imbalance result.
It is not the result of insulin administration.
The nurse is preparing to administer pain medication to an older adult. To promote safety,
which would the nurse assess before giving the medication?
Blood pressure
Client’s pain level rating

Bowel sounds and function

Other prescribed medications

Rationale
Older adults are frequently prescribed multiple medications that can have side effects when combined with
analgesics. Therefore, the nurse would assess which other medications the client is taking before
administering analgesics. Blood pressure, pain level, and bowel sounds should be assessed, but these
assessments do not promote safety.

Which finding would lead the nurse to contact the state bureau of motor vehicles to obtain
a driving evaluation for an older adult?
Cancer

Arthritis
Dementia

Depression
Rationale
A client with cognitive deficits such as dementia may lead the nurse to contact the state bureau of motor
vehicles. Confusion that accompanies dementia could place the client and others at risk if the client were
driving. Cancer, arthritis, and depression do not normally lead to driving impairment.

Which information would the nurse provide an older adult and caregivers regarding
medication safety? Select all that apply. One, some, or all responses may be correct.
Use a pill organizer.

Read all medication labels.

Place pills in unlabeled bottles.

Review medications with pharmacist.

Empty medicine cabinet every 2 years.

Rationale
The nurse would instruct the client and caregivers regarding medication safety. This includes using a pill
organizer or calendar to remember doses and days to take medications. The nurse would also emphasize the
importance of reading all medication labels for possible warnings. The client should review medications with
the pharmacist or health care provider. Pills should never be placed in unlabeled bottles because this can lead
to confusion about which medication it is. The medicine cabinet should be emptied at least every year for
expired medications and old prescriptions.
Which would be placed in the medical record before implementing the use of restraints?
A prescription from the health care provider

Approval of the department of mental health

Documentation that the client is not alert and oriented

Pharmacological efforts to control the client have failed.

Rationale
Federal requirements indicate that use of any restraint, physical or chemical, requires a prescription from the
health care provider. The facility does not require approval from the department of mental health. Clients
requiring restraints may be combative or at risk for self-harm and not just disoriented. Pharmacological
efforts are considered a form of chemical restraint.

Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong
answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about
that condition would help you choose the correct response (e.g., cholecystectomy = a low-fat, high-protein, low-calorie
diet).

After a below-the-knee amputation, a client is refusing to eat, talk, or perform any

rehabilitative activities. Which approach would the nurse take when interacting with this
client?
Explain why there is a need to increase activity.
 Emphasize that with a prosthesis, there will be a return to the previous lifestyle.

Appear cheerful and noncritical regardless of the client’s response to attempts at intervention.
Acknowledge that the client’s withdrawal is an expected and necessary part of initial grieving.

Rationale
The withdrawal provides time for the client to assimilate what has occurred and to integrate the change in
body image. The client is not ready to hear explanations about why there is a need to increase activity until
assimilation of the surgery has occurred. Emphasizing a return to the previous lifestyle does not acknowledge
that the client must grieve; it also does not allow the client to express any feelings that life will never be the
same again. In addition, it may be false reassurance. The client might feel that the nurse has no
comprehension of the situation or understanding of feelings if the nurse appears cheerful and noncritical
regardless of the client’s response to attempts at intervention.

A depressed client is prescribed citalopram hydrobromide. Six days later, the client tearfully
says to the nurse, 'I’m taking an antidepressant, but it’s not working. I’m hopeless.' Which
response would the nurse give?
'You feel hopeless.'

'It’s easy to get discouraged.'

'It takes 2 or 3 weeks before it begins to relieve depression.'

'Give it a little more time; it works more slowly in some people.'

Rationale
Informing the client about the expected response to the medication is factual information that may decrease
the client’s sense of hopelessness. Although empathic responses may be helpful, at this time the client needs
information and reassurance based on fact. Citalopram hydrobromide does not work more slowly in some
people.

The nurse is teaching a client who is receiving a monoamine oxidase inhibitor about dietary
restrictions. The nurse plans to caution the client to avoid which foods?
Pork, spinach, and fresh oysters

Milk, grapes, and meat tenderizers

Cheese, beer, and products with chocolate

Leafy green vegetables, fresh apples, and ice cream

Rationale
Cheese, beer, and products with chocolate are high in tyramine, which in the presence of a monoamine
oxidase inhibitor can cause an excessive epinephrine-type response that can result in a hypertensive crisis.
There is no relationship between monoamine oxidase inhibitors and pork, spinach, oysters, milk, grapes, meat
tenderizers, leafy green vegetables, apples, or ice cream.

Test-Taking Tip: Monitor questions that you answer with an educated guess or changed your answer from the
first option you selected. This will help you analyze your ability to think critically. Usually your first answer is
correct and should not be changed without reason.
Which key factor would the nurse consider when assessing how a client will cope with body
image changes?
Suddenness of the change
Obviousness of the change

Extent of the change

Perception of the change

Rationale
It is not the reality of the change, but the client’s feeling about the change, that is most important in
determining a client’s ability to cope. Although the suddenness, obviousness, and extent of the body change
are relevant, they are not as significant as the client’s perception of the change.

Which side effect would the nurse monitor for in a severely depressed client who received
electroconvulsive therapy (ECT)?
Loss of appetite

Postural hypotension
Total memory loss

Confusion immediately after the treatment

Rationale
The nurse would monitor for confusion immediately after the treatment. The electrical energy passing
through the cerebral cortex during ECT results in a temporary state of confusion after treatment. Loss of
appetite, postural hypotension, and total memory loss are not usual or expected side effects. Memory loss is
usually restored after a few months of treatment.

Which condition would be a contraindication to electroconvulsive therapy (ECT)?

Brain tumor

Type 1 diabetes
Hypothyroid disorder

Urinary tract infection

Rationale
ECT is contraindicated in the presence of a brain tumor, because the treatment causes an increase in
intracranial pressure. ECT is not contraindicated in the presence of diabetes, hypothyroidism, or urinary tract
infection.

Which action would the nurse take for a client who is a psychologist and has questioned the
authority of the treatment team and advised other clients that their treatment plans are
wrong?
Tell the other clients to disregard what the client is saying.
 Ignore the client’s disruptive behavior while waiting for it to subside.
Restrict the client’s contact with other clients until the disruptive behavior ceases.

Accept that the client is unable to control this behavior while setting appropriate limits.

Rationale
The nurse would accept that the client is unable to control this behavior while setting appropriate limits.
Clients who are out of control need to have limits set for them. The staff must understand that the client is
not deliberately trying to disrupt the unit. Telling the other clients to disregard what the client is saying is
demeaning the client in the eyes of the other clients and does not address the problem directly. Ignoring the
client will not stop the disruptive behavior; also, the nurse has a responsibility to the other clients. Restricting
the client’s contact with other clients until the disruptive behavior ceases may be done as a last resort, but this
approach would not be used until other alternatives have been explored.

Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize
the right answer when they see it or that the right answer will somehow stand out from the other choices. This
is a dangerous misconception. The more carefully the question is constructed, the more each of the choices
will seem like the correct response.

A client with a history of schizophrenia who responds poorly to medication is now being
treated for acute depression. In light of the information elicited from the medication list
and laboratory results, which information would the nurse provide?
 'Come in for weekly blood tests to monitor for medication-induced agranulocytosis.'

'Report incidents of unusual bleeding or easy bruising while taking fluoxetine.'

'Expect to be prescribed only 1 week’s supply of fluoxetine at a time.'

'Consume a high-protein diet to offset the risk of anemia while taking clozapine.'

Rationale
The antipsychotic medication clozapine poses a risk for the development of agranulocytosis, especially when
combined with a selective serotonin reuptake inhibitor such as fluoxetine. The client’s neutrophil and white
blood cell counts (WBCs) are borderline and therefore suggestive of the disorder. Weekly blood testing to
monitor these blood values is required. The client’s platelet count is in the low-normal range, but fluoxetine is
not generally considered a factor in bleeding disorders. Clozapine, not fluoxetine, would likely be prescribed
on a week-by-week basis to both help manage side effects and encourage weekly visits for lab work. Clozapine
is not generally considered a factor in the development of anemia.

The nurse would identify which medication as a high-potency medication used to treat
schizophrenia?
Loxapine
Thioridazine

Fluphenazine
Perphenazine
Rationale
Fluphenazine is a high-potency medication used for schizophrenia. Loxapine and perphenazine are medium-
potency medications used to treat schizophrenia. Thioridazine is a low-potency medication used to treat
schizophrenia.

Which term describes a display of anger that is socially unacceptable?

Abuse
Battery

Aggression
Defensiveness

Rationale
Experiencing and demonstrating anger is a normal human reaction; however, aggression is manifest when
behaviors are socially and emotionally unacceptable. Abuse is a general term that infers physical, sexual,
emotional, or verbal mistreatment of another individual. Battery involves harmful or offensive touching or
physical contact. Defensiveness is protection of oneself against a real or perceived threat.

Which term describes the disturbance in mood and affect seen in clients who are
depressed?
Euphoric
Labile
 Expansive
Dysphoric

Rationale
Dysphoric describes feelings of hopelessness and sadness, which are symptomatic of depression. Euphoric is a
feeling of elation and joyfulness; this is often seen in the early manic phase of bipolar disorder. A labile mood
describes a rapid change in mood, for example, clients with dementia may be easily upset and then happy. An
expansive (talkative, exaggerated friendliness) mood is usually associated with the manic phase of bipolar
disorder.

STUDY TIP: Do not change your pattern of study. It obviously has contributed to your being here, so it
worked. If you have studied alone, continue to study alone. If you have studied in a group, form a study group.

Which statement is accurate for adolescent suicide behavior?

Boys account for more attempts compared with girls.
Girls use more dramatic methods compared with boys.

Girls talk more about suicide before attempting it.

Boys are more likely to use lethal methods than are girls.

Rationale
The finding that boys are more likely to use lethal methods than are girls is supported by research; girls
account for 90% of suicide attempts, but boys are three times more successful because of the methods they
use. Statistics do not support the assertion that girls talk more about suicide before attempting it than do boys
or that girls use more dramatic methods than do boys.

Which intervention would the nurse include when developing a plan of care for a client in
the manic phase of bipolar disorder?
Focus the client’s interest in reminiscing.
Encourage the client to talk as much as needed.
Persuade the client to complete any task that has been started.
Redirect the client’s excess energy to more constructive activities.

Rationale
The hyperactive client usually is easily distracted, so excess energy can be redirected into constructive
channels. The client with bipolar disorder, manic phase, does not need to reminisce. The client in the manic
phase will talk a great deal with no encouragement. The client in the manic phase will not be able to focus
long enough on one task to finish it.

Test-Taking Tip: Do not read too much into the question or worry that it is a 'trick.' If you have nursing
experience, ask yourself how a classmate who is inexperienced would answer this question from only the
information provided in the textbooks or given in the lectures.
A client expresses a complete lack of interest in food. How would the nurse document this
finding in the client's medical record?
Apathy
Aphasia

Adactyly
Anorexia

Rationale
Anorexia refers to loss of appetite. Apathy refers to lack of concern or emotion. Aphasia is the absence of or
inability to produce communication through speech. Adactyly refers to the absence of digits on the hands or
feet.

Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the
correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in
one or two of the options . Example: If the item relates to and identifies stroke rehabilitation as its focus and only
one of the options contains the word 'stroke' in relation to rehabilitation, you are safe in identifying this choice as the
correct response.

Which type of sexual disorder describes a client who has a sexual obsession with shoes?
Select all that apply. One, some, or all responses may be correct.
Sexual sadism
 Fetishistic
Pedophilic

Voyeuristic
Frotteuristic
Exhibitionistic

Rationale
Having a fetish is to become sexually aroused by something that would not be typically arousing. A fetishistic
disorder is characterized by a sexual focus on objects (such as shoes, gloves, pantyhose, and stockings) that are
intimately associated with the human body. Sadism is achievement of sexual satisfaction from the physical or
psychological suffering (including humiliation) of a victim. Pedophilic disorder is a predominant or exclusive
sexual interest toward prepubescent children. Voyeurism is characterized by seeking sexual arousal through
the viewing (usually secret) of other people engaged in intimate situations. Rubbing or touching a non-
consenting person is frotteuristic disorder. Exhibitionistic disorder involves the intentional display of the
genitals in a public place.

Which therapeutic communication technique would be useful for a client with major
depressive disorder?  Select all that apply.  One, some, or all responses may be correct.
Reflecting

Offering self
Using silence
 Paraphrasing

Asking open-ended questions

Encouraging comparison

Rationale
Reflection helps clients better understand their own thoughts and feelings. Offering self means the nurse
demonstrates interest and desire to understand. Silence gives clients time to collect their thoughts.
Paraphrasing means to restate the basic content of a client’s message in different, usually fewer, words. The
nurse may confirm an interpretation of the client’s message by using simple, precise, and culturally relevant
terms, before the interview continues. Open-ended questions encourage clients to share information about
experiences. Encouraging comparison brings out recurring themes and helps clients clarify similarities and
differences.

Test-Taking Tip: Do not select answers that contain exceptions to the general rule, controversial material, or
degrading responses.

Arrange the initial step and subsequent sequence of stages of behavior change according to
the stages of change model.

1. Precontemplation

2. Contemplation
 3.
Preparation

4. Action

5. Maintenance

6. Relapse

Rationale
The first step is precontemplation, where the client acknowledges the behavior problem that needs to change.
This is followed by contemplation, which is defined as acknowledging the problem and being sure of wanting
change. Next is preparation, which means getting ready to change. This is followed by action, which is defined
as changing the behavior. Next is maintenance, which means to maintain the changed behavior. Finally, there
is relapse, which is defined as returning to older behaviors and abandoning the new changes.

A child with cystic fibrosis (CF) has been admitted with a respiratory infection. The child has
been very disruptive and angry with staff and parents. Which reason would the nurse
suspect is the cause for the child’s uncooperative behavior?
Spoiled and needs to be adequately disciplined
Resentful of the restriction of the hospitalizations
 Having a reaction to the new respiratory medications
Angry about dietary restrictions related to the disease

Rationale
Children with CF often become resentful of repeated hospitalizations, the disease itself, and restrictions on
their activities. It is judgmental to assume that the child is spoiled, and the child has had dietary restrictions in
place since diagnosis of the disease, so this is not a new issue. Although new medications may have side
effects, they are rarely behavioral in nature.

Which characteristic uniquely associated with psychophysiological disorders would

differentiate them from somatic symptom disorders?
Emotional cause
Feeling of illness
Restriction of activities

Underlying pathophysiology

Rationale
Psychophysiological disorders have an underlying pathophysiology or actual physical cause, whereas somatic
symptom disorders usually do not. The psychophysiological response (e.g., hyperfunction or hypofunction)
produces actual tissue change. Somatic symptom disorders are unrelated to organic changes. There is an
emotional component in both instances. There is a feeling of illness in both instances. There may be a
restriction of activities in both instances.

Which primary feeling would the nurse anticipate that clients with bulimia nervosa
experience after an episode of bingeing?
Guilt
Paranoia
Euphoria

Satisfaction

Rationale
Guilt is a primary feeling clients experience after a bingeing episode. A sense of being out of control
accompanies the consumption of large amounts of food, resulting in guilt, depression, and disgust with one’s
self. Paranoia is associated with schizophrenia and paranoid personality disorder, not with bulimia nervosa.
After bingeing, a person with bulimia nervosa usually feels guilt rather than euphoria or satisfaction because
these clients are aware that the eating pattern is abnormal.

In light of a nurse hearing a depressed client telling another client, 'I’ll be feeling better
soon,' which initial parameter would the nurse assess for in the depressed client?
Ability to sleep
Suicidal thinking
 Current feelings of depression
Subjective ideas about treatment progress

Rationale
The nurse would assess the client’s suicidal thinking. The client’s comment reflects the possibility of suicide;
further assessment and protection of the client are necessary. Although sleep is affected by depression, the
overheard comment does not make this a priority at this time. Although feelings of depression could be
getting better and subjective ideas about treatment progress could be improving, neither is the priority at this
time. These assessments can be addressed after the assessment for suicide.

Which response would the nurse make to a client scheduled for electroconvulsive therapy
(ECT) who says, 'I’m scared that I’ll lose my memory forever after the treatment'?
'Your memory loss may be permanent, but usually it’s just temporary.'
'You won’t experience a permanent memory loss, so there’s no need to be frightened.'

'You’ll experience a temporary loss of memory, and feeling frightened about it is expected.'
'Your memory loss will be temporary, and it will help block out many of your painful past experiences.'

Rationale
The nurse would respond with, 'You’ll experience a temporary loss of memory, and feeling frightened about it
is expected.' Giving the client simple facts and assuring the client that being frightened is expected may help
ease the client’s fears. Memory loss affects recently learned information such as the ECT experience; the
response that it may be permanent may unnecessarily worry the client. Although it is a true statement that
memory loss is not permanent and there is no need to worry, this response negates the client’s feelings. ECT
does not selectively block out painful experiences.

Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct
answer.

A client with hepatic cirrhosis begins to exhibit slurred speech, confusion, drowsiness, and a
flapping tremor. Based upon this assessment, which prescribed diet would the nurse
anticipate?
No protein
Moderate protein
High protein

Strict protein restriction

Rationale
Because the liver is unable to detoxify ammonia to urea and the client is experiencing clinical manifestations
leading to an impending hepatic encephalopathy coma, protein intake should be moderate. Strict protein and
no-protein restrictions are not required because the client needs protein for healing. The hepatic
encephalopathy diagnosis contradicts high-protein intake because protein breaks down into ammonia.

Test-Taking Tip: After choosing an answer, go back and reread the question stem along with your chosen
answer. Does it fit correctly? The choice that grammatically fits the stem and contains the correct information
is the best choice.

The nurse is working with an older adult brought to the emergency department after
sustaining multiple falls at home. The nurse suspects alcohol abuse. Which finding places
the client at risk for injury?
Depression
Self-neglect
Malnutrition
Lack of insight

Rationale
Lack of insight can occur in older adults who have excessive alcohol intake. This can place the client at risk for
injury because the client is unable to think through the ramifications of his or her actions. Depression, self-
neglect, and malnutrition are physical and mental manifestations of alcohol abuse but do not directly place
the client at risk for injury.

Test-Taking Tip: Look for options that are similar in nature. If all are correct, either the question is poor or all
options are incorrect, the latter of which is more likely. Example: If the answer you are seeking is directed to a
specific treatment and all but one option deal with signs and symptoms, you would be correct in choosing the
treatment-specific option.
The nurse is working with a group of clients in a mental health facility. The nurse would
assess risk for suicide in clients with which conditions? Select all that apply. One, some, or
all responses may be correct.
Anxiety
Alcohol abuse

Schizophrenia
Bipolar disorder
Attention deficit disorder

Rationale
Certain mental health disorders increase a person’s risk for suicide. These include anxiety, alcohol abuse,
schizophrenia, and bipolar disorder. Attention deficit disorder does not increase a person’s risk for suicide.

A client has been receiving lithium for the past 2 weeks for the treatment of bipolar
disorder, manic phase. Which information will the nurse include in the teaching plan for
this client?
A diuretic is necessary for anyone taking lithium.

Lithium must be taken for the rest of the client’s life.

The blood level of lithium must be checked every month.
A low-sodium diet must be followed while lithium is being taken.
Rationale
Lithium’s therapeutic window is very narrow, and a toxic level may accumulate in the body unless routine
checks of the medication’s concentration in the blood are performed. During the acute phase of mania, the
therapeutic blood level of lithium should be between 1.0 and 1.5 mEq/L (1.0–1.5 mmol/L); the maintenance
therapeutic blood level of lithium ranges from 0.5 and 1.2 mEq/L (0.5–1.2 mmol/L). Diuretics reduce sodium
and should be avoided; lithium is not excreted when the sodium level is decreased, resulting in toxicity.
Lithium may or may not need to be taken for the rest of a client’s life. A low-sodium diet can lead to
hyponatremia, which must be avoided because it limits the excretion of lithium, resulting in toxicity.

Test-Taking Tip: Become familiar with reading questions on a computer screen. Familiarity reduces anxiety
and decreases errors.

Which side effect would the nurse monitor for when administering a selective serotonin
reuptake inhibitor (SSRI)? Select all that apply. One, some, or all responses may be correct.
Anxiety
Nausea

Sedation
Restlessness
Suicidal ideation
Increased energy level
Rationale
Clients on SSRIs would be assessed for changes in attitude (anxiety, restlessness) and suicidal gestures.
Depressed people may attempt suicide when taking antidepressants as a result of increased energy levels,
which can lead to a renewed interest in suicide. Other side effects of SSRIs include nausea, sedation, dry
mouth, vomiting, constipation, diarrhea, anorexia, differences in taste, headache, tremor, dizziness, weakness,
fatigue, increased sweating, sexual dysfunction, visual disturbances, and urinary problems.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked
to select all options that apply to a given situation or client. All options likely relate to the situation, but only
some of the options may relate directly to the situation.

The nurse is administering hydroxyzine to a client. The nurse would monitor the client for
which side effect of this medication?
Ataxia

Drowsiness
Vertigo
Slurred speech

Rationale
Hydroxyzine suppresses activity in key regions of the subcortical area of the central nervous system; it also has
antihistaminic and anticholinergic effects. Ataxia, vertigo and slurred speech are not associated with
hydroxyzine.

Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no
pattern to the answers.

A client is prescribed imipramine 75 mg three times per day. Which nursing action is
appropriate when administering this medication?
Telling the client steroids will not be prescribed

Warning the client not to eat cheese

Monitoring the client for increased tolerance
Having the client checked for increased intraocular pressure

Rationale
Glaucoma is one of the side effects of imipramine, and the client should be taught about the symptoms. The
prescribing of steroids and avoiding cheese are true of monoamine oxidase inhibitors (MAOIs); imipramine is
not an MAOI. Tolerance is not an issue with tricyclic antidepressants such as imipramine.

Test-Taking Tip: The most reliable way to ensure that you select the correct response to a multiple-choice
question is to recall it. Depend on your learning and memory to furnish the answer to the question. To do
this, read the stem and then stop! Do not look at the response options yet. Try to recall what you know and,
based on this, what you would give as the answer. After you have taken a few seconds to do this, then look at
all of the choices and select the one that most nearly matches the answer you recalled. It is important that you
consider all the choices and not just choose the first option that seems to fit the answer you recall. Remember
the distractors. The second choice may look okay, but the fourth choice may be worded in a way that makes it
a slightly better choice. If you do not weigh all the choices, you are not maximizing your chances of correctly
answering each question.

A client is prescribed a monoamine oxidase inhibitor (MAOI) for depression. The nurse
includes teaching on foods and medications known to cause serious adverse effects when
used in combination with MAOIs. Which adverse effect would the nurse include in the
teaching plan?
A serious drop in blood pressure
A serious increase in blood pressure
A significant increase in liver enzymes
A significant increase in cholesterol levels

Rationale
MAOIs, when taken with foods high in tyramine (e.g., pickled foods, beer, wine, aged cheeses), medications
such as antidepressants, certain pain medications, and decongestants can cause a life-threatening increase
(not decrease) in blood pressure or hypertensive crisis. For this reason, they are seldom used to treat
symptoms of depression. MAOIs do not increase liver enzymes or cholesterol levels.

Test-Taking Tip: Monitor questions that you answer with an educated guess or changed your answer from the
first option you selected. This will help you analyze your ability to think critically. Usually your first answer is
correct and should not be changed without reason.
Which intervention would be important when caring for a client who was admitted
yesterday with borderline personality disorder (BPD)?
Setting limits
Offering advice

Being an attentive listener

Encouraging group activities

Rationale
Setting limits is the important intervention. Because clients with BPD are often manipulative and have a sense
of entitlement, it is crucial for limits on behavior to be set. Offering advice is nontherapeutic for any client.
Being an attentive listener is useful in exploring situations but will be most effective after clear behavioral
limits are set, and clients with BPD can be manipulative with an attentive listener. Initially, encouraging group
activities are not helpful for clients with BPD, because the behavior is often associated with difficulty
controlling anger and affect instability, including irritability and anxiety. Later in the hospital stay, group
activities may occur.

Test-Taking Tip: Do not spend too much time on one question, because it can compromise your overall
performance. There is no deduction for incorrect answers, so you are not penalized for guessing. You cannot
leave an answer blank; therefore, guess. Go for it! Remember: You do not have to get all the questions correct
to pass.

In which room would the nurse manager place a client with bipolar disorder, manic
episode?
One that has basic simple furnishings
One that will provide a variety of stimuli

One with another client who is very quiet

One with another client exhibiting mania

Rationale
The nurse would place the client in one that has basic simple furnishings. Clients with mania are stimulated
by environmental factors. One responsibility of the nurse is to simplify their surroundings as much as
possible. During this phase, the client needs a decrease in stimuli. Thus, a room that provides a variety of
stimuli is nontherapeutic. The quiet client may become the target of this client’s overactivity. Placing two
overactive clients together may produce excessive stimulation, becoming nontherapeutic.

Test-Taking Tip: Be aware that information from previously asked questions may help you respond to other
examination questions.

The nurse is reviewing discharge plans with a client who is hospitalized with hepatitis A. The
nurse concludes that the client understands preventive measures to reduce the risk of
spreading the disease when the client makes which statement?
'I should wash my hands frequently.'

'I should launder my clothes separately.'

 'I should put used tissues in the garbage.'
'I should wear a mask when leaving the house.'

Rationale
Hepatitis A microorganisms are transmitted via the anal-oral route; hand washing, particularly after toileting,
is the most important precaution. The response 'I should launder my clothes separately' will not deter the
spread of the virus; hand washing is necessary. Putting used tissue in the garbage is important, but hand
washing is the most important precaution. Hepatitis A microorganisms exit through the rectum, not the
respiratory tract.

A client with Laënnec cirrhosis experiences ascites, jaundice, and confusion. Which is a
nursing priority when caring for this client?
Correcting nutritional deficiencies
Measuring abdominal girth every day

Providing for the client’s physical safety

Placing the client in the high-Fowler position

Rationale
Hepatic encephalopathy, related to high ammonia levels, results in central nervous system derangement;
physical safety is the priority. Although correcting nutritional deficiencies is important, it is not the priority.
Although measuring abdominal girth is important, it is not the priority. The high-Fowler position will be
uncomfortable because of the pressure of the distended abdomen against the legs. The semi-Fowler position
is more appropriate, and it promotes respiration.

A client with a diagnosis of dementia of the Alzheimer type has been taking donepezil 10
mg/day for 3 months. The client’s partner calls the clinic and reports that the client has
increasing restlessness and agitation accompanied by nausea. Which advice would the
nurse give the partner?
Give the medication with food.

Administer the medication at bedtime.

Omit 1 dose today and start with a lower dose tomorrow.
Bring the partner to the clinic for testing and a physical examination.

Rationale
Many people with dementia experience physical problems such as urinary tract infections but cannot
adequately verbalize what is happening. They may just become more restless and agitated. Because the client
has been taking this dose for 3 months, the problems probably are not being caused by the medication. The
client should be brought in for an evaluation. Taking the medication with meals is recommended to decrease
gastrointestinal side effects, but this client is experiencing more than this. Donepezil can cause insomnia. The
client is already restless and agitated. Taking the medication at bedtime will not help. The nurse would not
advise a modification of the dosage without consulting the health care provider.
A prescription calls for the administration of 5 mg of haloperidol intramuscularly PRN (as
needed) for severely agitated and aggressive behavior. The haloperidol is available in a vial

labeled 2 mg/mL. How many milliliters of solution will the nurse administer? Record your
answer using one decimal place. 2.5
mL

Rationale
The amount is 2.5 mL. Use ratio and proportion to solve this problem.

Which cellular process associated with type 1 diabetes mellitus results in increased client
fatigue?
Increased metabolism at the cellular level
Increased glucose absorption from the intestine

Decreased production of insulin by the pancreas

Decreased glucose secretion into the renal tubules

Rationale
Insulin facilitates transport of glucose across the cell membrane to meet metabolic needs and prevent fatigue.
With diabetes there is decreased cellular metabolism because of the decrease in glucose entering the cells.
Glucose is not absorbed from the intestinal tract by the cells; fatigue is caused by decreased, not increased,
cellular levels of glucose. Filtration and excretion of glucose by the kidneys do not regulate energy levels; if
insulin production is adequate, glucose does not spill into the urine.

The nurse suspects that an adolescent has anorexia nervosa. Which characteristics may have
been observed in the adolescent? Select all that apply. One, some, or all responses may be
correct.
Denying illness
Dismissing food
Seeking intimacy

Being extroverted
Maintaining rigid body control

Rationale
Anorexia nervosa is a complex disorder that can result in morbidity and mortality. Denying the illness,
dismissing food, and maintaining rigid control of the body are characteristics observed in adolescents with
anorexia nervosa. Seeking intimacy and being extroverted are characteristics of bulimia nervosa.

The spouse of a client who had a cerebrovascular accident asks the home health nurse why
the client cries easily and without provocation. Which response would the nurse provide?
This is a way of getting attention that should be ignored.
 The client can remember only depressing events from the past.
The client feels guilty about the demands being placed on the family.
This behavior is a common response over which the client has little control.

Rationale
If the client exhibits emotional instability, this usually is caused by lesions that affect the thalamic area in the
part of the neural system most responsible for emotions. Attention-getting behavior requires cognitive
thinking, and lability of mood is unrelated to this. The client may have remote memory, but there is no
selective process that determines which events are remembered. There are no data to come to the conclusion
that the client is experiencing feelings of guilt.

Family members of a client who had a brain attack (cerebrovascular accident, CVA) ask why
the client cries easily and without provocation. Which explanation would the nurse provide
about the client’s behavior?
Has little control over this behavior

Is making an attempt to get attention

Feels guilty about the demands being made on the family
Has selective memory from the past, especially the sad events

Rationale
Emotional instability usually is caused by lesions affecting the thalamic area (the part of the neural system
most responsible for emotions). Crying easily is not attention-getting behavior; lability of mood is a
physiological response to the CVA. The client may have remote memory, but there is no selective process of
what events are remembered. There are inadequate data to come to the conclusion that the client feels guilt.
Lability of mood is a physiological response to the CVA.

One week after an above-the-knee amputation, a client refuses to go to physical therapy

and tells the nurse, 'I’ll never be a whole person again!' Which response would the nurse
make?
'You’re still the same person you’ve always been. Just relax.'
'You’ve lost a part of yourself. That must be difficult for you.'
'You may feel that way, but I’m sure your family considers you a whole person.'

'You must go to physical therapy every day or you will develop muscle contractures.'

Rationale
The response 'You’ve lost a part of yourself. That must be very difficult for you' acknowledges and reflects the
client’s feelings and encourages further communication. The response 'You’re still the same person you’ve
always been. Just relax' negates the client’s feelings. The nurse does not know how the client’s family members
feel; the response 'You may feel that way, but I’m sure your family considers you a whole person' takes the
focus off the client. The response 'You must go to physical therapy every day or you will develop muscle
contractures' is true, but telling the client this serves no therapeutic purpose at this time.

Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe
need additional time, but then relax and get a good night’s sleep. Remember to set your alarm, allowing
yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good
breakfast, and arrive at the testing site at least 15 to 30 minutes early.

A depressed client is prescribed 37.5 mg of venlafaxine three times a day by mouth. The

pharmacy supplies scored 25 mg tablets. How many tablets would the nurse administer at
the next scheduled administration time? Record your answer using one decimal place.

1.5
tablet(s)

Rationale
There are three ways to calculate the number of tablets needed for the next scheduled medication
administration:

Using ratio and proportion: 25 mg : 1 tab :: 37.5 mg : x tab(s); 25X = 37.5; x = 37.5/25 = 1.5

Using dimensional analysis: 37.5 mg x 1 tab/25 mg = 37.5/25 = 1.5

Using desire/have x Q (tabs): 37.5 mg/25 mg x 1 tab = 37.5/25 = 1.5

While caring for a client on phenelzine, the nurse notes an excess elevation of the person’s
temperature. Which medication being taken concurrently by the client may be responsible
for this condition?
 Meperidine
Desipramine
Amitriptyline
Amphetamine

Rationale
Phenelzine is a monoamine oxidase inhibitor (MAOI) used to treat depression. Meperidine is a strong
analgesic that when taken concurrently with MAOIs may result in excessive temperature elevation.
Desipramine and amitriptyline are tricyclic antidepressants that may cause hypertensive episodes or
hypertensive crisis when taken concurrently with MAOIs. Amphetamine is an indirectly acting
sympathomimetic that causes a hypertensive crisis when taken concurrently with MAOIs.

Which statement of a client confirms that he or she has reached the intimacy versus
isolation stage according to Erikson’s theory of psychosocial development?
'I donate a large sum of money to the local school every year.'
'I want to enjoy my motherhood and that’s why I am leaving the job.'

'In the winter of my life, I feel that I do not have anyone to take care of me.'
'I did so much for my partner, but I was dumped for someone more attractive.'
Rationale
In the intimacy versus isolation stage, a young adult develops a sense of identity and deepens his or her
capacity to love and care for others. A statement that exemplifies this stage is one from a client who says that
he or she did so much for his or her partner but still got dumped for someone more attractive. An example of
the generativity versus self-absorption and stagnation stage is if a client says that he or she donates a large
sum of money to the local school every year. An older adult says that he or she feels that he or she does not
have anyone to take care of him or her is in the integrity versus despair stage.

Which are the characteristics of the phallic stage, per Freud’s psychoanalytical model of
personality development? Select all that apply. One, some, or all responses may be
correct.
A child may develop an oedipal complex.

A girl may experience 'penis envy' feelings.

The genital organs are the focus of pleasure.
Sexual urges revive and are directed to an individual outside the family circle.

A child begins to realize that the mother or parent is something separate from the self.

Rationale
According to Freud’s psychoanalytical model of personality development, in the phallic stage, a child may
develop an oedipal complex, which is defined as a time of exploration and imagination when the child
fantasizes about the parent of the opposite sex as his or her first love interest. In the phallic stage, a girl may
become aware of the absence of a penis; this is known as 'penis envy.' In the phallic stage, the genital organs
become the focus of pleasure. In the genital stage, sexual urges revive and are directed at an individual
outside the family circle. In the oral stage, a child begins to realize that the parent is separate from the self.

A client has several episodes of uncontrolled rage. While watching violent behaviors on a
television newscast, the client says, 'Those people need to be put away before they kill
someone.' Which defense mechanism is the client is using?
Denial
Projection

Introjection
Sublimation

Rationale
The client is projecting her thoughts about herself on to others. Denial involves ignoring or disavowing
unacceptable thoughts, wishes, or feelings. Introjection is the process of taking in someone else's values,
beliefs, attitudes, or qualities. Sublimation is the channeling of unacceptable thoughts or feelings into
acceptable activities.

A client who has severe facial scarring from burns tells the nurse, 'I've saved some
oxycodone, and when I get home, I'm going to take all of them. Don't tell anyone.' Which
response is best?
 'Are you planning to kill yourself?'
'Why don't you want me to tell anyone?'

'Are you in a lot of pain right now?'

'How much oxycodone do you have?'

Rationale
A direct assessment is necessary to determine whether the client is contemplating suicide. The client already
has stated that the nurse should not tell anyone. Asking 'why' is an indirect method to assess motivation and
behavior, but 'why' questions are usually avoided because they can spawn justification and evasion. Pain
management is not the priority at this time; pain may not be the reason for taking the medication. Asking
about quantity of available oxycodone is a follow-up question to assess means.

Which response is best to give a parent who asks about childhood suicide?
'Suicide threats from children of any age should be taken seriously.'
'Children do not have readily available means to kill themselves.'
'Children younger than age 6 may threaten but don't attempt suicide.'
'Suicide attempts in young children are manipulations to control their parents.'

Rationale
Suicide threats and gestures are a means of communicating anger, frustration, hopelessness, and despair to
significant others and should always be taken seriously. Children have many means readily available; many
common objects around the home and playground can be used to commit suicide. Although suicide is the
second leading cause of death in the 15- to 24-year-old group, children younger than age 6 do attempt
suicide, and some succeed. A suicide attempt is usually self-destructive; it is not an attempt to manipulate or
control others.

Test-Taking Tip: Choose the best answer for questions asking for a single answer. More than one answer may
be correct, but one answer may contain more information or more important information than another
answer.

A client who is extremely depressed after losing his job because of downsizing says, 'I’m a
useless, worthless person. No wonder I lost my job.' Which feeling state is the client
expressing?
Paranoia
Persecution
Loss of control
Self-deprecation

Rationale
The client’s statement is self-derogatory and reflects a low self-appraisal. The client is not experiencing
paranoia, persecution, or loss of control; he feels like he deserves what happened.
Which behavior is typical for antisocial personality disorder?
Sexual acting out
Disregard for others
Loss of contact with reality

Compulsive, repetitive behaviors

Rationale
Clients with antisocial personality disorder usually have a history of interpersonal difficulties. They are unable
to engage in the give-and-take a relationship requires because of their consistent disregard for and
exploitation of others. There is no direct relationship between antisocial personality disorders and sexual
acting out. Loss of contact with reality is not characteristic for the personality disorders. Compulsive behaviors
are associated with obsessive-compulsive disorder.

Which explanation is true for childhood depression?

May appear as acting-out behavior

Looks almost identical to adult depression

Does not respond to conventional treatment
Is short in duration and has an early resolution
Rationale
Children have difficulty verbally expressing their feelings; acting-out behaviors, such as temper tantrums, may
indicate an underlying depression. Adult and childhood depression may be manifested in different ways.
Many conventional therapies for adults with depression, including medication, are effective for children with
depression. Childhood depression is not necessarily short-term and requires treatment.

A client is having a manic episode and has not eaten in the 2 weeks preceding
hospitalization. Which rationale explains the eating pattern?
The client has feelings of unworthiness.
The client’s activity level interferes with eating.
The client unconsciously desires punishment.
The client is preoccupied with ritualistic behavior.

Rationale
During a manic episode the affected individual tries to keep active to prevent depression; avoidance of
feelings, not food, is the priority, and manic people do not take the time to eat. Feelings of grandeur have
replaced unconscious feelings of unworthiness at this phase of the illness. The manic phase is not
characterized by a desire for punishment. Manic clients are usually not aware of unconscious feelings. Clients
in the manic phase do not control anxiety by the use of ritualistic behavior; ritualistic behavior is common in
clients with an obsessive-compulsive disorder.

For a client with the diagnosis of major depression, which problem is the most common?
 Loss of faith in God
Visual hallucinations

Decreased social interaction

Loss of family support

Rationale
Depressed clients demonstrate decreased social interaction because of a lack of psychic or physical energy.
They tend to withdraw, speak in monosyllables, and avoid contact with others. Loss of faith and visual
hallucinations can occur but are less commonly associated with major depression. Hallucinations are typically
associated with schizophrenic disorders. Loss of family support can occur because of client withdrawal, but
many family members will remain hopeful and supportive.

Which signs and symptoms are associated with mood disorder, hypomanic episode? Select
all that apply. One, some, or all responses may be correct.
Distractibility
Flight of ideas
Low self-esteem
Increased need for sleep

Psychomotor retardation
Rationale
These individuals have a short attention span; their attention is easily drawn to unimportant or irrelevant
external stimuli. They shift from one idea or topic to another and express their thoughts in a rapid flow of
speech. They have an inflated self-esteem or grandiosity. There is a decreased need for sleep. Psychomotor
agitation or an increase in goal-directed activity is expected.

Which behavior would alert the nurse that a child is demonstrating outwardly focused
anger or aggression in an overt manner?
Dominating a class discussion
Intentionally forgetting to do homework

Scribbling on a classmate’s art assignment

Crying when told he or she must wait his or her turn

Rationale
Scribbling on a classmate’s art assignment is outwardly focused anger or aggression in an overt manner.
Overt anger is demonstrated obviously or in an unconcealed manner that is hurtful, such as in damaging the
artwork of another student. Examples of passive outwardly focused anger would be in dominating a class
discussion or intentionally forgetting to do something that is required. Crying is a demonstration of inwardly
focused frustration or inability to delay gratification that is objectively displayed when having to wait his or her
turn.

Test-Taking Tip: Try putting questions and answers in your own words to test your understanding.
For a client who is demonstrating manic behavior, which behavior is the most important to
monitor?
Withdrawal can lead to social isolation.
Speech patterns may inhibit verbalizing needs.
Overeating can result in weight gain.

Excessive activity may cause exhaustion.

Rationale
The elated client expends a great deal of energy; dehydration, oxygen deficit, cardiac problems, and death may
occur. The elated person does not withdraw from reality but continues to run headfirst into reality. The elated
client has little difficulty verbalizing needs. The elated client usually does not take time to eat while expending
a great deal of energy, so weight loss is the problem.

During an admission interview, a client is expansive and distractible and demonstrates a

fragmented, pressured, nonsequential pattern of speech. Which communication technique
would the nurse use?
Closed questions

Active listening
Paraphrasing
Open-ended questions
Rationale
The client demonstrates flight of ideas and other behaviors seen in the manic phase of bipolar disorder. The
nurse must use highly structured closed questions to help the client focus on a single topic. Active listening,
paraphrasing, and open-ended questions are excellent techniques that encourage clients to express feelings,
explore options and problem-solve; however, when the goal is to obtain specific information (e.g., admission
interview), these techniques are not a good choice for clients in the manic phase.

Test-Taking Tip: Be aware that information from previously asked questions may help you respond to other
examination questions.

Which response would the nurse use for a client who appears dejected, barely responds to
questions, and in a barely audible voice says, 'Life is no longer worth living'?
'Have you been thinking about suicide?'
'What could be so bad to make you feel that way?'

'We'll talk about your feelings after you've rested.'

'Let's talk about something pleasant to make you feel better.'

Rationale
It is important to determine whether the client is thinking about suicide; the direct approach is most effective.
The client’s feelings are denied by 'What could be so bad?' and this response also suggests that the client has
no right to feel that way. The client’s feelings are not the priority if the client is made to wait until 'after you've
rested.' Changing the subject by 'talking about something pleasant' is a block to communication.
The grieving spouse of a client who has just died says, 'We should have spent more time
together. I always felt that my work came first.' Which interpretation would the nurse make?
Spouse is displacing anger on the deceased for dying
Spouse is expressing feelings of guilt over lost opportunities

Spouse is having ambivalent feelings about the deceased

Spouse is feeling shame for past behavior and interactions

Rationale
The spouse is expressing the typical feelings of guilt associated with the death of a loved one; often there is
initial guilt over what might have been. No evidence supports displaced anger or ambivalent feelings about
the spouse. The spouse is expressing guilt (feelings of contrition toward others), not shame (feelings of
humiliation for self ). The nurse would conduct an additional assessment before arriving at any conclusions
about anger, ambivalence, or shame.

Which response is the most therapeutic to give to a client who says, 'If I have to have a
colon resection and colostomy, I know that my husband will never come near me again'?
'You're probably underestimating his love for you.'
'Are you worried that the surgery will change how others see you?'
'You're concerned about how your husband will respond to your surgery.'
'Are you wondering about the effect of surgery on your sexual function?'
Rationale
Reflecting concerns and using an open-ended response encourages further discussion. The nurse would avoid
platitudes or making assumptions about the marital relationship. The client specifically referred to her
husband, not other people. Sexual function may be a client concern, but the nurse needs to perform
additional assessment before broaching this topic.

The nurse receives a telephone call from an adolescent who expresses suicidal ideations.
Which client response indicates that the nurse can safely terminate the call?
The adolescent verbalizes a desire to terminate the conversation.
The nurse's initial assessment of suicide risk is completed.
The adolescent repeats information that has already been discussed.

The adolescent formulates an action plan to control self-harm behaviors.

Rationale
The client should be able to state specific behaviors that can be used to decrease self-destructive thoughts and
actions. Terminating the conversation is ineffective because the client may end the conversation and remain
suicidal. Risk assessment is the first step of the nursing process, but the dialogue should continue until a
contract has been set or self-destructive behaviors have diminished. Repeating the same information that has
already been discussed indicates the client has not reached catharsis and needs to continue talking to the
nurse.

Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the
alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response
question that requires you to choose 2 or more of the given alternatives. If a fill-in-the-blank question poses a
problem, read the situation and essential information carefully and then formulate your response.

Which long-term outcome would the nurse add to the plan of care for a client experiencing
a major depressive episode?
Will talk openly about the depressed feelings
Will identify and use new defense mechanisms

Will discuss the unconscious source of the anger

Will verbalize realistic perceptions of self and others

Rationale
The long-term goal is to verbalize realistic perceptions of self and others. A major part of depression involves
an inability to accept the self and others as is. Talking about the client’s depressed feelings is a short-term
goal; looking at what is causing those feelings is a long-term goal. Developing new defense mechanisms is
not a long-term goal, because they tend to help the client avoid reality. Discussing the unconscious source of
the anger is not a long-term goal for major depressive episodes; the long-term goal is to change the client’s
perspective.

Test-Taking Tip: The most reliable way to ensure that you select the correct response to a multiple-choice
question is to recall it. Depend on your learning and memory to furnish the answer to the question. To do
this, read the stem, and then stop! Do not look at the response options yet. Try to recall what you know and,
based on this, what you would give as the answer. After you have taken a few seconds to do this, then look at
all of the choices and select the one that most nearly matches the answer you recalled. It is important that you
consider all the choices and not just choose the first option that seems to fit the answer you recall. Remember
the distractors. The second choice may look okay, but the fourth choice may be worded in a way that makes it
a slightly better choice. If you do not weigh all the choices, you are not maximizing your chances of correctly
answering each question.

Which statement would the nurse make to a newly admitted, depressed, tearful client who
looks intently at the nurse but says nothing when the nurse offers to walk with the client to
the lunch table?
'I’ll be at the desk if you need me.'
'You must tell me what you’re feeling now.'

'We’ll walk together to dinner when you calm down.'

'It must be very difficult for you to be on a psychiatric unit.'

Rationale
The statement, 'It must be very difficult for you to be on a psychiatric unit,' lets the newly admitted client know
that the nurse realizes the client is having difficulty without asking direct questions or focusing on specific
behavior. The response, 'I’ll be at the desk if you need me,' connotes avoidance. Saying, 'You must tell me what
you’re feeling now,' sounds more like an order than an opportunity to express feelings. Saying, 'We’ll walk
together to dinner when you calm down,' negates the client’s feelings and there is no data to support that the
client needs to 'calm down.'
Which response would the health clinic nurse make to a young college student who reports
increasing anxiety, loss of appetite, and an inability to concentrate?
'With whom have you shared your feelings of anxiety?'
'What have you identified as the cause of your anxiety?'
'It’s been difficult for you. How long has this been going on?'

'Let’s talk about your problems. Are you having difficulty adjusting?'

Rationale
The nurse would say, 'It’s been difficult for you. How long has this been going on?' Noting that the situation
has been difficult for the client and asking how long it has lasted acknowledges the client’s feelings and
attempts to collect more data. Asking with whom the client has shared the situation will not facilitate the
collection of data about the extent of anxiety. Anxiety is most often a response to a vague, nonspecific threat;
the client will not be able to explain what causes it. It is too early to try to identify the cause of the anxiety;
crisis intervention with anxious clients requires a more structured approach than, 'Let’s talk,' and asking if the
student is having difficulty adjusting is premature. There is not enough data for that conclusion.

Which technique would the nurse implement to provide suicide precautions for a newly
admitted suicidal client?
Keeping the client in the lounge during the daytime

Encouraging the client to express feelings frequently

Assigning a staff member to be with the client at all times
 Having an unlicensed assistive personnel observe the client every half hour at night

Rationale
The nurse would assign a staff member to be with the client at all times. Emotional support and close
surveillance can demonstrate the staff ’s caring and their attempt to prevent the client from acting on suicidal
ideation. Although surveillance may meet the client’s safety needs (keeping the client in the lounge during the
daytime), it does not meet the client’s emotional needs. Also, the client would still have the opportunity to
attempt suicide at night. Encouraging the client to express feelings frequently is not a suicide precaution.
Having an unlicensed assistive personnel check the client every half hour at night is unsafe; the client could
still find a way to carry out a suicide attempt in the room.

Which action would the nurse take when a young adult client becomes very agitated after
the parents’ visit?
Take the client to the coffee shop for a treat.

Distract the client by providing a unit activity.

Limit the client’s future contact with the parents.
Explore the client’s response to the parents’ behavior.

Rationale
The nurse would explore the client’s response to the parents’ behavior. Helping the client explore his or her
reactions to the parents’ visit may provide insight to the client’s reactions and enhance effective coping
strategies. Taking the client to the coffee shop for a treat ignores the necessity of clarifying the client’s
response to the family visit. Distraction is not a therapeutic way to deal with realistic feelings. Limiting the
client’s future contact with the parents is a temporary measure and does not allow the client to take
responsibility for his or her feelings.

Which best response would the nurse make to a client with severe anxiety who starts to cry
uncontrollably while talking with the nurse?
'Talking about your problem is upsetting you.'
'It’s okay to cry; I’ll just stay with you for now.'
'Sometimes it helps to get it out of your system.'

'You look upset; let’s talk about why you’re crying.'

Rationale
The nurse would say, 'It’s okay to cry; I’ll just stay with you for now.' Telling the client that it is all right to cry
and offering to stay presents a nonjudgmental attitude that recognizes the client’s needs and shows
acceptance by the nurse. Although saying, 'Talking about your problem is upsetting you' is appropriate, it is
not the best response because the nurse is making an observation rather than showing acceptance. Telling the
client that it helps to get it out of the system implies that crying will make the client feel better and therefore
is false reassurance. Although saying the client looks upset is acceptable, it is not the best because the nurse
uses 'why,' which can put the client on the defensive. Asking the client to describe why is unrealistic; the
anxiety level must be lowered before a discussion can begin.

Test-Taking Tip: A psychological technique used to boost your test-taking confidence is to look into a mirror
whenever you pass one and say out loud, 'I know the material, and I'll do well on the test.' Try it; many
students have found that it works because it reduces 'test anxiety.'

Which signs and symptoms would the nurse observe in a client with bipolar disorder,
depressed episode?
Elated affect related to reaction formation
Loose associations related to a thought disorder

Physical exhaustion related to decreased physical activity

Paucity of verbal expression related to slowed thought processes

Rationale
Thought processes become slower and verbal expressions decrease because of lack of emotional energy
during the depressive phase. Elation is associated with bipolar disorder, manic episode; the affect of a
depressed person is usually one of sadness, or it may be blank. Loose associations are related to
schizophrenia, not depression. Physical exhaustion is associated with bipolar disorder, manic episode;
decreased physical activity does not produce physical exhaustion.

Which intervention would the nurse perform for an extremely agitated client who begins to
pace around the mental health dayroom?
Locking the client in the client’s room to limit external stimuli
 Letting the client pace in the hall away from other clients

Getting the client involved in a card game to distract the client’s thoughts
Encouraging the client to work with another client on a unit task

Rationale
Letting the client pace in the hall away from other clients allows the client to work off energy without
upsetting other clients. Locking the client in the client’s room to limit external stimuli will isolate the client
and is illegal unless the client presents an actual danger to self or others. The client’s current emotional state
limits concentration, so a card game would be ineffective. The client’s current emotional state prevents
interaction with others; therefore, encouraging the client to work with another client on a unit task will be
unproductive.

Which behavior would the nurse observe in a client who has a histrionic personality
disorder?
Boastful and egotistical
Rigid and perfectionistic
Extroverted and dramatic
Aggressive and manipulative

Rationale
Clients with a histrionic personality disorder are extroverted and dramatic. Clients with histrionic personality
disorder draw attention to themselves, are vain, and demonstrate emotionality and attention-seeking
behavior. Boastful and egotistical behaviors are typical of clients with the diagnosis of narcissistic personality
disorder. Rigid and perfectionistic behaviors are typical of clients with the diagnosis of obsessive-compulsive
personality disorder. Aggressive and manipulative behaviors are typical of clients with the diagnosis of
antisocial personality disorder.

STUDY TIP: When forming a study group, carefully select members for your group. Choose students who have
abilities and motivation similar to your own. Look for students who have a different learning style than you.
Exchange names, email addresses, and phone numbers. Plan a schedule for when and how often you will
meet. Plan an agenda for each meeting. You may exchange lecture notes and discuss content for clarity or
quiz one another on the material. You could also create your own practice tests or make flash cards that review
key vocabulary terms.

Which conclusion would the nurse make when the depressed client says, 'You know I’m a
sorry, lazy person. I don’t deserve a job'?
Is experiencing nihilistic delusions

Has delusions of persecution

Has feelings of self-deprecation
Is experiencing depersonalization

Rationale
The client has feelings of self-deprecation. The client’s statements are self-derogatory and reveal low self-
esteem. There is no evidence of feelings about nonexistence (nihilistic delusions). There is no evidence that
the client feels controlled or manipulated by others (delusions of persecution). There is no evidence that the
client has a feeling of unreality or of alienation from the self (depersonalization).

Which intervention would be essential for the nurse to take for a hyperactive client?
Using a firm but caring and consistent approach
Anticipating and physically controlling the hyperactivity
Allowing the client to choose the activities in which to participate
Letting the client know that the staff will not tolerate overactive behavior

Rationale
Using a firm but caring and consistent approach will help reduce the client’s anxiety, thereby reducing
hyperactivity. It is not possible to physically control hyperactivity. The client is not capable of choosing
activities at this time. The staff would know how to deal with overactive behavior; the client may not be capable
of controlling overactive behavior.

Which objective would be priority for a young child with attention-deficit/hyperactivity

disorder who demonstrates intermittent head-banging and hair-pulling?
Facilitating sleep

Maintaining safety
 Promoting body image
Increasing nutritional intake

Rationale
The priority is maintaining safety. Intermittent head-banging and hair-pulling are self-destructive behaviors
that may result in injury; prevention of self-injury has the highest priority. Facilitating sleep, promoting body
image, and increasing nutritional intake are not the most important nursing objectives in light of the data
presented; prevention of self-injury is primary.

Which discharge criterion would be appropriate for a client with obsessive-compulsive

disorder who is using ritualistic behaviors?
Verbalizes positive aspects about self
Follows the rules of the therapeutic milieu

Is able to intervene when increasing levels of anxiety occur

Recognizes that hallucinations occur at times of extreme anxiety

Rationale
A discharge criterion for a client using ritualistic behaviors is to be able to intervene when increasing levels of
anxiety occur. Knowing when and how to intervene to hold increasing anxiety at a manageable level will result
from teaching the client to recognize situations that provoke ritualistic behavior and how to interrupt the
pattern. Neither verbalizing positive aspects of the self nor following the rules of the therapeutic milieu is an
appropriate criterion for ritualistic behavior. Clients with obsessive-compulsive disorder do not hallucinate.

Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be
clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices
by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a
four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall
often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago
had seemed completely forgotten.

Which response would the nurse make to a client’s partner who does not understand the
rationale of using a daycare environment for the client’s obsessive-compulsive disorder?
'This environment limits time to carry out the rituals.'

'A neutral atmosphere facilitates the working through of conflicts.'

'A location that requires no decision-making will resolve feelings of anxiety.'
'This daycare setting allows the staff to exert control over unacceptable behaviors.'

Rationale
The nurse would say, 'A neutral atmosphere facilitates the working through of conflicts.' These clients can
better work through their underlying problems when the environment is structured, demands are reduced,
and the routine is simple. Preventing these clients from carrying out rituals may precipitate panic reactions.
Although eliminating the necessity to make decisions may decrease anxiety, simple decision-making would be
encouraged. The intention of therapy should be to help the client gain control, not to enable others to do the
controlling.

Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be
clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices
by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a
four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall
often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago
had seemed completely forgotten.

Which action would the nurse take for a depressed client who often sleeps past the expected
time of awakening and spends excessive time resting and sleeping?
Encourage client participation in daily activities.
Offer the client a series of relaxation recordings.
Reschedule the client’s bedtime to an earlier hour.
Suggest that the client exercise before going to bed.

Rationale
The nurse would encourage the client’s participation in daily activities. Most people require 6 to 8 hours of
rest at night. Too much sleep (hypersomnia), particularly during the daytime, will undermine the client’s
ability to receive adequate rest at night. Offering the client a series of relaxation recordings or rescheduling
the client’s bedtime to an earlier hour will actually promote hypersomnia rather than preventing it. Suggesting
that the client exercise before going to bed will increase the metabolic rate and is not conducive to adequate
rest.

Test-Taking Tip: Being emotionally prepared for an examination is key to your success. Proper use of
resources over an extended period of time ensures your understanding and increases your confidence about
your nursing knowledge. Your lifelong dream of becoming a nurse is now within your reach! You are excited,
yet anxious. This feeling is normal. A little anxiety can be good because it increases awareness of reality; but
excessive anxiety has the opposite effect, acting as a barrier and keeping you from reaching your goal. Your
attitude about yourself and your goals will help keep you focused, adding to your strength and inner
conviction to achieve success.

Which action would a group of nursing students take when a client with bipolar disorder,
manic episode, tells them, 'I’m being held against my will, and I plan to escape later today'?
Inform the primary nurse of the client’s behavior and plan.
Wait to discuss the issue during postconference with the nursing instructor.
Meet with the hospital security staff to alert them of the client’s vague escape plan.

Introduce the interaction during the afternoon community group meeting.

Rationale
The group of nursing students would inform the primary nurse of the client’s behavior and plan.
Communication of significant information to the appropriate health team member as soon as possible
facilitates immediate assessment and a possible change in the plan of care to maintain the client’s safety.
Waiting to discuss the issue during postconference with the nursing instructor delays the assessment process,
jeopardizing the client’s safety. Meeting with the hospital security staff to alert them of the client’s vague
escape plan bypasses the professional nursing staff, who can assess the elopement risk and prevent any
violation of client rights. Introducing the interaction during the afternoon community group meeting delays
the assessment process, which may jeopardize the client’s safety; also, confronting the client in front of a
group is not therapeutic.

Test-Taking Tip: As you answer each question, write a few words about why you think that answer is correct; in
other words, justify why you selected that answer. If an answer you provide is a guess, mark the question to
identify it. This will permit you to recognize areas that need further review. It will also help you see how correct
your 'guessing' can be. Remember: on the licensure examination you must answer each question before
moving on to the next question.

Which action would the nurse take when working with a client who is depressed?
Accept what the client says.
Attempt to keep the client occupied.
Keep the client’s surroundings cheery.
Try to prevent the client from talking too much.

Rationale
The action is to accept what the client says. Because clients cannot be argued out of their feelings, it is best to
initially accept what they say; it also encourages communication. Attempting to keep the client occupied
delays discussing the client’s feelings, and the client’s low energy level may prevent involvement in activities.
Keeping the client’s surroundings cheery has little effect on the depressed client; it can increase depression.
The depressed client does very little talking and needs to be encouraged to communicate.

Test-Taking Tip: A psychological technique used to boost your test-taking confidence is to look into a mirror
whenever you pass one and say out loud, 'I know the material, and I'll do well on the test.' Try it; many
students have found that it works because it reduces 'test anxiety.'

Which response would the nurse make to a client with the diagnosis of bipolar disorder
who tells the nurse, 'I’ve hidden a razor blade, and tonight I’m going to kill myself'?
'You’re going to kill yourself?'
'Things really can’t be that bad.'
'Are you sure you really mean that?'
'Killing yourself is not going to solve your problems.'

Rationale
The response, 'You’re going to kill yourself?' focuses on the client’s statement and does not challenge or deny
it. It provides the client with an opportunity to verbalize further. The response, 'Things really can’t be that bad,'
negates the client’s feelings and interprets the situation for the client. The response, 'Are you sure you really
mean that?' demeans the client and denies the client’s feelings. The response, 'Killing yourself is not going to
solve your problems,' denies the client’s feelings and belittles the client.

Test-Taking Tip: Stay away from other nervous students before the test. Stop reviewing at least 30 minutes
before the test. Take a walk, go to the library and read a magazine, listen to music, or do something else that
is relaxing. Go to the test room a few minutes before class time so that you are not rushed in settling down in
your seat. Tune out what others are saying. Crowd tension is contagious, so stay away from it.

Which behavior would alert the school nurse that a second-grader has attention-
deficit/hyperactivity disorder (ADHD)?
Hostility
Impulsivity

Excellent testing ability

Positive peer relationships

Rationale
The nurse would observe impulsivity. Criteria for the diagnosis of ADHD includes maladaptive behavior
lasting at least 6 months and characterized by impulsiveness, inattention, and overactivity. Impulsivity often
results in unsafe behaviors. Hostility is more characteristic of oppositional defiant disorder. Excellent testing
ability is uncommon in ADHD. Inattention to detail, careless mistakes, and difficulty organizing work, which
are associated with ADHD, hinder the affected child’s test-taking ability. Peer relationships are usually strained
and of short duration.

Which initial intervention would be implemented when a depressed client says, 'I’m no
good. I’m better off dead'?
 Respond, 'I’ll stay with you until you’re less depressed.'
Reply, 'I think you’re good; you should think about living.'
Alert the staff to schedule a 24-hour observation of the client.
Unobtrusively remove those articles that may be used in a suicide attempt.

Rationale
Alerting the staff to schedule a 24-hour observation of the client is the most therapeutic approach to
preventing suicide. A staff member also provides special attention to help the client meet dependency needs
and reduce a self-defeating attitude. Staying with the client until the depression eases is unrealistic, because
the nurse cannot be with the client constantly until the depression lifts. Replying, 'I think you’re good; you
should think about living,' negates the client’s feelings and cuts off further communication. Although
potentially hazardous objects should be removed, the initial intervention is a 24-hour observation of the client.

Which response would the nurse make to a client with depression who is sitting by the
window crying?
'It’s okay. No need to cry or worry while you’re here. We all feel down now and then.'
'Please don’t consider suicide. It really isn’t an appropriate way out of your troubles.'
'You seem to be experiencing a sad moment. I’ll sit here with you for a while and talk if you would
like.'
'Why don’t you go into the dayroom and join the card game going on? That’ll take your mind off of
your problems for a while.'
Rationale
The nurse would say, 'You seem to be experiencing a sad moment. I’ll sit here with you for a while and talk if
you would like.' The nurse is acknowledging that the client is feeling especially down and offering to be
available for discussion or just to provide a presence. Telling the client not to cry and that we all feel down now
and then belittles the client’s feelings. The response regarding suicide is judgmental and may discourage any
effort by the client to initiate a discussion. Suggesting a card game does not acknowledge the client’s feelings
and appears to trivialize the client’s feelings.

Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize
the right answer when they see it or that the right answer will somehow stand out from the other choices. This
is a dangerous misconception. The more carefully the question is constructed, the more each of the choices
will seem like the correct response.

Which action would the nurse take for a withdrawn client who refuses to get out of bed and
becomes upset when asked to do so?
Require the client to get out of bed.
Stay with the client until the client calms down.
Give the client the as needed (PRN) antipsychotic that is prescribed.
Leave the client alone in bed for as long as the client wishes.

Rationale
The nurse would stay with the client until the client calms down. This action provides support and security
without rejecting the client or placing value judgments on the behavior. Eventually limits will have to be set in
giving care but staying with the client and showing acceptance are immediate nursing actions. The nurse
would not require the client to get out of bed as this leads to a power struggle. Although giving the client the
PRN antipsychotic will calm the client, it does not address the immediate problem. Administering the
medication may need to occur later, if the behavior escalates. Leaving the client alone in bed for as long as the
client wishes ignores the problem and for a withdrawn client this could last for days.

Test-Taking Tip: Being prepared reduces your stress or tension level and helps you maintain a positive
attitude.

Which initial behavior would the nurse help a client with major depressive disorder
complete?
Develop rapport with the nurse.
Investigate new leisure activities.

Participate in small-group activities.

Initiate conversations about feelings.

Rationale
The nurse would help the client develop rapport with the nurse. Before therapy can be started, a trusting
relationship must be developed. A client with major depression does not have the impetus or energy to
investigate new leisure activities. Participating in small-group activities is not appropriate initially; a trusting
one-on-one relationship must be developed first. Initiating conversations about feelings will not be successful
unless the client has developed a trusting, comfortable relationship with the nurse.

Test-Taking Tip: As you answer each question, write a few words about why you think that answer is correct; in
other words, justify why you selected that answer. If an answer you provide is a guess, mark the question to
identify it. This will permit you to recognize areas that need further review. It will also help you see how correct
your 'guessing' can be. Remember: on the licensure examination you must answer each question before
moving on to the next question.

Which statement would the nurse make when discharging a depressed client from the
mental health unit?
'I’m going to miss you; we’ve become good friends.'

'I know that you’re going to be all right when you go home.'
'Call the contact number we gave you if you have an emergency.'
'This is my phone number; call and let me know how you’re doing.'

Rationale
Instructing the client to call the contact number that was provided in case of emergency demonstrates an
understanding that the newly discharged client needs to have a support system. Clients need to feel that in a
crisis there will be someone there for them. The role of the nurse is not to become a good friend but instead
to help the client function. The statement 'I know you’re going to be all right when you go home' provides
false reassurance; the nurse does not know this. Saying 'This is my phone number; call and let me know how
you’re doing' is unprofessional and blurs the roles of nurse and client.

Test-Taking Tip: Do not panic while taking an exam! Panic will only increase your anxiety. Stop for a moment,
close your eyes, take a few deep breaths, and resume review of the question.

Which condition would be the priority to assess for during the initial appointment for a
client with bulimia nervosa?
Insight
Boredom

Loneliness
Depression

Rationale
Depression commonly coexists with bulimia nervosa; it is the priority to assess the client’s level of depression
to prevent self-harm. Safety of the client is a priority. Although insight, boredom, and loneliness are all
important assessments, none of these are the priority. These conditions do not affect client safety like
depression does.

Which approach would the nurse use for a client with major depression who refuses to
participate in unit activities, claiming to be 'just too tired'?
Planning 1 rest period during each activity
 Explaining why the staff believes that the activities are therapeutic
Encouraging the client to express negative feelings about the activities
Accepting the client’s feelings about activities while calmly setting firm limits

Rationale
Fatigue and apathy are symptoms of depression and should be accepted; however, limits would be set to
facilitate participation in unit activities. Planning 1 rest period during each activity allows the client to
manipulate the environment. Explaining why the staff believes that the activities are therapeutic will not
change the client’s mind about them, and this response does not show an understanding of the client’s needs.
Encouraging the client to express negative feelings about the activities will reinforce negative feelings about
participating in them and would be counterproductive.

Which complication is an adverse effect of cortisone therapy?

Hypoglycemia
Severe anorexia
Anaphylactic shock
Behavioral changes

Rationale
Development of mood swings and psychosis is possible during long-term therapy with glucocorticoids
because of fluid and electrolyte alterations. Hypoglycemia, severe anorexia, and anaphylactic shock are not
responses to long-term glucocorticoid therapy.

A female client who had a colostomy recently is asking questions about how normal her life
will be now that she has a colostomy. Which statement by the client indicates a need for
further teaching?
'I wanted another child, and now pregnancy is not an option for me.'
'I must allow extra time for irrigating my colostomy when traveling.'
'It is good to know that I can swim every day after my incision heals.'

'I’m glad I won’t have to have special clothing and I can wear what I have.'

Rationale
Pregnancy is possible; it should be determined whether the client is referring to physiological capability or
emotional concern about sexual relationships. Extra time usually is necessary in an unfamiliar environment
and should be calculated into traveling plans. Swimming is permitted; the water will not injure the stoma or
intestine. There are no adaptations or restrictions on the types of clothing.

Test-Taking Tip: Eat breakfast or lunch before an exam. Avoid greasy, heavy foods and overeating. This will
help keep you calm and give you energy.

The nurse is caring for a client who was brought to the emergency department after binge
drinking at a party. Which interventions would the nurse include in the plan of care to
prevent a suicide attempt? Select all that apply. One, some, or all responses may be
correct.
Keep door closed for privacy.

Allow phone and charger in room.

Require sitter in room at all times.
Verify medications are swallowed.
Use plastic utensils and paper cups.

Rationale
Suicide precautions that should be part of the plan of care for a client on suicide precautions include the use
of a safety sitter to stay in the client’s room 24 hours a day to provide direct observation at all times. The nurse
would verify the client has swallowed all medications administered to prevent hoarding. Clients who plan
suicide may attempt to pocket all medications and take them all at once to carry out the plan. The use of
plastic utensils and paper cups prevent self-harm from regular utensils and glass cups. The door should
remain open at all times for direct observation. The nurse would not permit the client to have the phone
charger in the room because the client can use the cord for self-harm.

The nurse identifies that a client seems to be depressed after a thymectomy for treatment of
myasthenia gravis. Which action would the nurse take?
Recognize that depression often occurs after this type of surgery.
 Ask the primary health care provider to arrange for a psychological consultation.
Reassure the client that things will feel better after the discharge date has been set.

Talk with the client and emphasize activities the client is still able to perform.

Rationale
Honest discussion with emphasis on functional and psychological abilities helps promote adjustment.
Postoperative depression is not a characteristic feature of thymectomy. Asking the client’s practitioner to
arrange for a psychological consultation is too soon; it may eventually be necessary if the client has difficulty
adjusting to the chronicity of this condition. Reassuring the client that things will feel better when the
discharge date is set provides false reassurance; there is no guarantee the client will feel better on discharge.

A client has a halo fixation device with a body cast place after sustaining a cervical neck
injury. Which statement indicates the client’s concern about body image has been resolved
successfully?
'I hate having everyone else do things for me all the time.'

'I’ve gotten used to the brace. I may even miss it when it’s gone.'
'I’ve been keeping my daily calories low in an attempt to lose weight.'
'I can’t get to sleep. However, I make up for it in the morning by sleeping later.'

Rationale
The client is demonstrating acceptance and is looking toward the future with the response, 'I’ve gotten used to
the brace. I may even miss it when it’s gone.' The response, 'I hate having everyone else do things for me,'
relates to low self-esteem, not body image disturbance. The response, 'I’ve been keeping my daily calories low
in an attempt to lose weight,' may indicate that the client may not accept the present body weight. Although
the response, 'I can’t get to sleep. However, I make up for it in the morning by sleeping later,' may indicate
adaptability, the statement is not related to body image.

Test-Taking Tip: Being emotionally prepared for an examination is key to your success. Proper use of
resources over an extended period of time ensures your understanding and increases your confidence about
your nursing knowledge. Your lifelong dream of becoming a nurse is now within your reach! You are excited,
yet anxious. This feeling is normal. A little anxiety can be good because it increases awareness of reality; but
excessive anxiety has the opposite effect, acting as a barrier and keeping you from reaching your goal. Your
attitude about yourself and your goals will help keep you focused, adding to your strength and inner
conviction to achieve success.

A client with Parkinson disease is admitted to the hospital. Which medication is prescribed
to improve the physical manifestations of Parkinson disease?
Carbidopa-levodopa
Isocarboxazid
Dopamine

Pyridoxine (vitamin B 6)
Rationale
Levodopa crosses the blood-brain barrier and converts to dopamine, a substance depleted in Parkinson
disease. Isocarboxazid is a monoamine oxidase inhibitor used for the treatment of psychological symptoms
associated with severe depression, not physiological symptoms of Parkinson disease. Dopamine is not
prescribed for this purpose because it does not cross the blood-brain barrier. Pyridoxine can reverse the effects
of some antiparkinsonian medications and is contraindicated.

Test-Taking Tip: Avoid selecting answers that state hospital rules or regulations as a reason or rationale for
action.

An adult child of a dying client says to the nurse, 'I am so upset because my parent is always
angry at me.' Which would be the correct response by the nurse?
'Your parent is frightened by impending death.'
'Your parent is working through acceptance of the situation.'
'Your parent is attempting to reduce your need for dependency.'

'Your parent is hurt that you will not provide physical care at home.'

Rationale
Understanding the stages leading to the acceptance of death may help the family member understand the
client’s moods and anger. The parent may not be frightened unless stated by the client; some clients welcome
death as a release from pain. It is unlikely that the parent is attempting to reduce the family member’s need
for dependency; anger is one of the stages of accepting death. It is an assumption by the nurse that the parent
is hurt that the family member will not provide physical care at home unless stated by the client.

When the primary health care provider prescribes 'bathroom privileges only' for a client with
an exacerbation of heart failure, the client becomes irritable and asks why bed rest is
needed. Which response by the nurse is best?
'Why do you want to be out of bed?'
'Bed rest plays a role in most therapy.'
'Rest reduces the amount of work your heart has to do right now.'

'Maybe the primary health care provider will increase your activity tomorrow.'

Rationale
A client’s knowledge about the treatment program enhances compliance and reduces stress. With heart failure
hospitalization, a decrease in activity level ('bathroom privileges only') is often temporarily needed until the
heart failure exacerbation resolves. The response, 'Why do you want to be out of bed?' does not answer the
client’s question and might produce frustration. The response, 'Bed rest plays a role in most therapy,' does
answer the client’s question, but does not explain specifically why. Because the nurse does not have the scope
of practice to change the provider’s activity prescription, the response, 'Maybe the primary health care provider
will increase your activity tomorrow,' is inappropriate.

Which medication would the nurse recognize as an effective mood-stabilizing medication

used in clients with bipolar disorder and in the acute treatment of mania and prevention of
recurrent mania and depressive episodes?
Doxepin

Clozapine
Amitriptyline
Lithium carbonate

Rationale
Lithium carbonate is often the first choice of treatment, once primary acute mania has been diagnosed, to
calm acute manic symptoms and relieve recurrent mania. Doxepin and amitriptyline are antidepressants used
to treat depression but not mania. Clozapine is an antipsychotic medication used to control hallucinations and
delusions in clients with psychosis but is not a first-line medication because of its side effects, which include
seizures and significant weight gain.

A 30-year-old who began lithium carbonate therapy 3 weeks ago is having blood drawn for
a lithium medication level. Which range will the nurse recognize as therapeutic?
0.1 to 0.3 mEq/L (0.1–0.3 mmol/L)
0.4 to 1.3 mEq/L (0.4–1.3 mmol/L)
1.5 to 1.9 mEq/L (1.5–1.9 mmol/L)

2.0 to 2.3 mEq/L (2.0–2.3 mmol/L)

Rationale
Lithium levels of 0.4 to 1.3 mEq/L (0.4–1.3 mmol/L) are therapeutic and effective in treating symptoms of
mania. A level below 0.3 mEq/L (0.3 mmol/L) is too low to be therapeutic. At levels above 1.5 mEq/L (1.5
mmol/L), early signs of toxicity may occur; at levels of 2.0 mEq/L (2.0 mmol/L) and higher, severe lithium
toxicity may occur, constituting a life-threatening emergency.

Test-Taking Tip: Make educated guesses when necessary.

The health care provider prescribes lithium citrate liquid 450 mg twice a day. The
medication is available as 300 mg/5 mL. How many milliliters of lithium solution will the

nurse administer? Record your answer using one decimal place. 7.5
mL

Rationale
Use ratio and proportion to solve this problem.

Place the stages of the grieving process according to Kübler-Ross in the correct order.

1. Denial

2. Anger
 3.
Bargaining

4. Depression

Rationale
The initial response is shock, disbelief, and denial, and the client seeks additional opinions to negate the
diagnosis. When negating the diagnosis is unsuccessful, the client becomes angry and negative. Bargaining
for wellness follows in an attempt to prolong life. As the reality of the situation becomes more apparent,
depression sets in and the client may become withdrawn.

Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. For
example, you might be asked the steps of performing a nursing action or skill, such as those involved in
medication administration.

The registered nurse (RN) instructed the nursing student to care for a client who suffers
from depression. During a follow-up visit, the RN finds that the client’s symptoms have not
improved. Which activity of the nursing student would the RN relate this to?
Modifying the environment

Limiting the client’s choices

Encouraging fluid intake
 Discouraging social interaction

Rationale
The nursing student’s act of discouraging interactions may result in a lack of improvement. Social interactions
should be encouraged instead. Modifying the environment may help provide better health care. The nurse
would limit the client’s choices to relieve any decision-making stress. The nurse would also encourage fluid
intake.

Which symptom indicates a possible drug interaction in a client taking monoamine oxidase
inhibitors (MAOIs) for depression?  Select all that apply. One, some, or all responses may
be correct.
Diarrhea
Dystonia
Dry mouth
Dyskinesia

Hypotension
Constricted pupils

Rationale
Antidepressants interact with a variety of other substances. Ingesting foods or drugs that contain tyramine or
certain vasopressors can overstimulate the nervous system. Side effects include dry mouth, constipation,
hypertension, dilated pupils, and changes in level of consciousness. Dystonia is impaired muscle tone.
Dyskinesia (the inability to execute voluntary movements) is an extrapyramidal side effect of antipsychotics and
is not associated with MAOIs.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The
client’s arterial blood gases deteriorate, and respiratory failure is impending. Which clinical
indicator is consistent with the client’s condition?
Cyanosis
Bradycardia
Mental confusion
Distended neck veins

Rationale
Decreased oxygen to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign
of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase
oxygen to body cells. Distended neck veins occur with fluid volume excess (e.g., pulmonary edema).

Test-Taking Tip: Do not select answers that contain exceptions to the general rule, controversial material, or
responses that appear to be degrading.
A client is to begin lithium carbonate therapy. Which baseline laboratory work will the nurse
ensure is completed before medication administration?
Renal studies

Cardiac enzyme studies

Adrenal function studies
Pulmonary function studies

Rationale
Because of the severity of side effects and the stress lithium places on the renal and cardiovascular systems, its
administration is contraindicated in clients with renal or cardiovascular disease. Baseline renal studies can be
used for comparison in the future. Baseline cardiac enzymes are not necessary before initiation of lithium
therapy; they are drawn when damage to the heart is suspected. Adrenal studies are not necessary; lithium
does not alter adrenal gland function. Pulmonary studies are not necessary; lithium does not cause alterations
in pulmonary function.

An older client is able to perform activities of daily living, but he has vague physical
complaints and has experienced multiple deaths of friends and family and has lost his social
roles. Which question is the most therapeutic?
'Can you cope with being alone?'
'Have you considered assisted living?'
'What is the main problem today?'
 'How do you feel about your life now?'

Rationale
An open-ended question is the most therapeutic invitation to encourage the client to discuss hopes and
frustrations without being threatening or probing. Closed questions (Can you cope? Have you considered?)
provide little information and are not the best choice for clients who need encouragement to verbalize feelings
and needs. Focusing on one main problem suggests that the client must limit his communication.

Test-Taking Tip: Do not read too much into the question or worry that it is a 'trick.' If you have nursing
experience, ask yourself how a classmate who is inexperienced would answer this question from only the
information provided in the textbooks or given in the lectures.

A client with the diagnosis of depression expresses a feeling of hopelessness. Which

additional behavior is the client most likely to display?
Outbursts of anger
Focused concentration
Preoccupation with delusions
Intense interpersonal relationships

Rationale
Clients who are depressed and feeling hopeless also tend to have inappropriate expressions of anger.
Depressed clients frequently have a diminished ability to think or concentrate. Preoccupation with delusions is
usually associated with clients who have schizophrenia, rather than with clients experiencing depression and
hopelessness. Clients who are depressed and feeling hopeless tend to be socially withdrawn and do not have
the physical or emotional energy for intense interpersonal relationships.

A client with major depressive disorder is most likely to experience which feeling?
Hedonia
Isolation

Paranoia
Ambivalence

Rationale
In an attempt to control anxiety, the client continues to retreat from people and the activities within the
environment; this will eventually precipitate feelings of loneliness and isolation. Depressed clients exhibit a
decreased interest in pleasurable activities (anhedonia) rather than an excessive interest in pleasurable
activities (hedonia). Paranoia and ambivalence could accompany depression, but these feelings are less likely
because they require more psychic energy.

Which behavior is typical of a depressed client?

Sets unrealistic goals
Engages in criminal activity
 Attempts to manipulate others
Overestimates current strengths

Rationale
A depressed client may formulate goals that are unrealistic and unattainable because of a lack of physical or
emotional energy. This may trigger further negative feelings and decrease self-esteem. Criminal activity is
typically associated with antisocial personality disorder. Depressed clients are experiencing cognitive
distortions and negativity and usually do not have a desire to manipulate others. Depressed clients are usually
unable to see their strengths and abilities as a result of their negative thinking.

A client with a bipolar disorder, depressed episode, displays an increase in depression over
the past month. Which behavior is expected?
Elated affect
Loose associations
Physical exhaustion
Slowed thought processes

Rationale
As depression increases, thought processes become slower and verbal expression decreases due to lack of
emotional energy. Elation is associated with bipolar disorder, manic episode; the affect of a depressed person
is usually one of sadness, or it may be blank. Loose associations are related to schizophrenia, not depression.
Physical exhaustion can occur during the manic episode of bipolar disorder.

For a client with a bipolar mood disorder, manic episode, which factor would the nurse
consider when planning care?
Client is likely to feel embarrassed by the manic behavior
Client is acutely aware of the environment and reality
Client should be able to control the acting-out behavior

Client is likely to engage in bingeing and purging behavior

Rationale
Manic individuals are acutely aware of what is happening and react strongly to environmental stimuli. These
clients are not out of contact with reality; in fact, they are continually reacting to it. These clients’ symptoms
are an attempt to avoid anxiety and do not cause embarrassment. They are unable to control acting-out
behavior. Bingeing and purging behavior is a symptom of bulimia.

Which factor causes the most difficulty for nurses who care for severely depressed clients?
Clients’ lack of energy
Negative cognitive processes
Client’s psychomotor retardation
 Contagious quality of depression

Rationale
Depression is contagious; it affects the nurse as well as the client. The insidious nature of contagious
depression can leave the nurse feeling drained and exhausted. Psychomotor retardation is usually
accompanied by lack of energy; these problems are readily addressed by nursing interventions. Negative
thinking gradually resolves with consistent use of therapeutic communication.

During the admission interview the client whose husband died 6 months ago avoids eye
contact, responds in a low voice, and is tearful. Which response would the nurse use?
'You’ll find that you’ll get better faster if you try to help us help you.'
'I’m your nurse. I’ll take you to the day room as soon as I get some information.'
'Here, hold my hand. I know you’re frightened, but I won’t let anyone harm you.'

'I know that this is difficult, but as soon as we’re finished I’ll take you to your room.'

Rationale
The nurse identifies the client’s feelings (this is difficult) and tells the client what will happen in the immediate
future (I’ll take you to your room). The nurse would avoid threats and false reassurance (you’ll get better faster)
or putting responsibility on the client (you must help us). Being with other people in a strange environment
(to the day room) will add more stress to the new and already frightening experience of hospitalization. The
client may think that the environment is unsafe (won’t let anyone harm you), and this could increase her
insecurity and anxiety.

A young adult client who has permanent paralysis secondary to a spinal cord injury says, 'I
wish God would end my suffering and take me.' Which response would the nurse use?
'You shouldn’t give up hope; things can change.'

'Being incapacitated is difficult for you.'

'Would you like to speak to a religious advisor?'
'Have you talked to your family about your feelings?'

Rationale
The nurse reflects feelings (incapacitation is difficult) by using an open-ended, accepting response; this
encourages the client to continue to express feelings. Platitudes (shouldn’t give up hope) and false reassurance
(things can change) are never useful to the client. Referring the discussion to a religious advisor is appropriate
if the client needs spiritual guidance, but if the client is trying to express feelings, the nurse would
immediately address that need. Evoking a family discussion turns the focus from the client’s feelings to the
family’s role.

As a client addicted to cocaine withdraws from the drug, which behavior would the nurse
observe?
Excitability
 Depression

Disinhibition
Hyperactivity

Rationale
The nurse would observe depression. Depression is one of the most serious side effects. Excitability occurs
with intoxication, not withdrawal. Disinhibition is commonly associated with alcohol intoxication.
Hyperactivity is more commonly associated with withdrawal from opioids, antianxiety drugs, or stimulant
intoxication.

Test-Taking Tip: Get a good night’s sleep before an exam. Staying up all night to study before an exam rarely
helps anyone. It usually interferes with the ability to concentrate.

Which behavior would indicate improvement in a severely depressed male client who
responds to therapy and, with the help of the staff, begins to set some daily objectives?
Staying clear of people who make him anxious

Talking with at least one person on the unit daily

Sitting alone several hours a day to think about personal concerns
Demonstrating to the staff that he can do what they want him to do
Rationale
The sign of improvement is talking with at least one person on the unit daily. Initiation of interactions
demonstrates that the depressed person is attempting to change behavior patterns. Avoiding people is a
reinforcement of the depressed lifestyle. Solitary activities are nonthreatening but do not deal with the
problem of impaired relationships in depressed clients. Clients who attempt to modify behavior to please
others make only superficial changes that are not lasting.

Test-Taking Tip: A psychological technique used to boost your test-taking confidence is to look into a mirror
whenever you pass one and say out loud, 'I know the material, and I’ll do well on the test.' Try it; many
students have found that it works because it reduces test anxiety.

When managing the care of an acutely depressed client, which approach would
demonstrate that the nurse recognizes the client’s fundamental mental health need?
Role modeling a hopeful attitude regarding life and the future
Sharing that life has presented depressing situations for all of us at times
Devoting time with the client while focusing on happy, positive memories

Identifying the client’s personal weaknesses to design interventions to strengthen them

Rationale
The nurse would role model a hopeful attitude regarding life and the future. Role modeling has been shown
to be an excellent tool in molding adaptive behavior. Depression affects the individual’s ability to see hope in
the future, and role modeling will help provide adaptation to similar feelings. Affirming that everyone has
depressive situations in their lives does not foster a positive response in the depressed client and belittles the
client’s feelings. Reminiscing about happier times and events is likely to highlight the client’s current loss of
happiness rather than foster positive feelings. When a client is depressed, the nurse would identify the client’s
personal strengths, not weaknesses, and focus on interventions to reinforce those strengths. Focusing on a
client’s weaknesses when the client is already depressed may initiate a deeper depression.

Which intervention is most helpful for a depressed client whose husband has recently died?
Involve the client in group exercises and other physical activities.
Motivate the client to interact with male clients and the nursing staff.
Talk with the client about her husband and the details of his death.
Encourage the client to talk about and plan for the future.

Rationale
Talking about the husband and his death will help the client work through the grief process. Depressed clients
usually do not have much physical or emotional energy for activities or for interacting with others. The client
must cope with the past and present before addressing the future.

STUDY TIP: Regular exercise, even if only a 10-minute brisk walk each day, aids in reducing stress. Although
you may have been able to enjoy regular sessions at the health club or at an exercise class several times a
week, you now may have to cut down on that time without giving up a set schedule for an exercise routine.
Using an exercise bicycle that has a book rack on it at home, the YMCA, or a health club can help you
accomplish two goals at once. You can exercise while beginning a reading assignment or while studying notes
for an exam. Listening to lecture recordings while doing floor exercises is another option. At least a couple of
times a week, however, the exercise routine should be done without the mental connection to school; time for
the mind to unwind is necessary, too.

A client with profoundly depressed behavior is undergoing a pretreatment evaluation for

electroconvulsive therapy (ECT), but the nurse is unsure if the client can provide informed
consent. Which intervention would the nurse use first?
Consult with the hospital’s legal staff and follow their recommendations.
Ask the client to verbalize understanding and the outcomes of the procedure.

Have the client sign the form, because she or he is considered legally competent.
Suggest that a family member sign the consent form for the client.

Rationale
The client’s understanding should be assessed first. Depressed clients are often cognitively stable and capable
of providing legal consent. Consultation with the hospital’s legal staff may eventually be necessary, but it is not
the initial action. The client’s rights are not protected if consent is obtained and the nurse believes that the
client does not comprehend the information. The client may be incompetent but not legally determined to be
incompetent; further assessment is necessary. Unless the client has legally granted the family member
authority to make decisions or the family member has been appointed as the client’s guardian by the court,
having a family member sign the consent is illegal.

For a client with recurrent episodes of depression, which factor contributes to the client’s
risk for suicide?
Psychomotor retardation
Decreased physical activity
Deliberate thoughtful behavior
Overwhelming feelings of guilt

Rationale
Overwhelming feelings of guilt contribute to the client’s risk for suicide. The client may ruminate over past or
current failings, and extreme guilt can assume psychotic proportions. Psychomotor retardation and decreased
physical activity are clinical findings associated with depression and usually do not lead to suicide because the
client does not have the energy for self-harm. Impulsive behaviors, not deliberate thoughtful behaviors,
contribute to the client’s risk for suicide.

A woman with bipolar disorder, manic episode, spent thousands of dollars on clothing and
makeup; then she started going to bars every night and rarely sleeps or eats. Which concept
is the priority in planning care for this client?
Mood and affect
Fatigue

Nutrition
Safety
Rationale
All of the concepts will be used in planning care for this client; however, safety is the priority concern. The
client shows an escalation of manic behavior that indicates poor judgment (excessive spending) and risky
behaviors (goes to bars every night) with hyperactivity that is interfering with daily needs (sleeping and eating).
Untreated the manic activity can progress to more dangerous behaviors (e.g., driving at high speed) and
adverse physical effects (e.g., cardiac collapse). The grandiosity will increase feelings or power and
invulnerability.

Which response would the nurse give when a client says, 'My therapist is uncaring and
impersonal'?
'Your therapist is really very good; he does care about you.'
'You can come to me or the other nurses whenever you need to.'

'The therapist is there to help you; it just takes a little time.'

'You have strong feelings about your therapist and the therapy.'

Rationale
The use of reflection assists the client in expressing feelings, which is the major goal of therapy. Telling the
client that the therapist is good is a defensive response that may cut off communication and limit the
expression of feelings. Directing the client to seek out the nursing staff may be appropriate for clients who are
very fearful, but in this case the response suggests 'us against the therapist.' Platitudes (takes a little time) may
be true, but this response blocks discussion of the client’s feelings about the therapist.
Which short-term goal is best for an adolescent client who had an angry outburst toward
another client in the dayroom?
Vent angry feelings to the other client in a private area
Talk about the situation that precipitated the anger
Apologize for the behavior in the community meeting

Ask for medication for when feelings of anger begin

Rationale
Talking about the episode may help the client gain insight into the behavior. This is essential before control
strategies can be developed. Continuing to vent angry feelings is inappropriate and may escalate the anger.
The client should apologize to the individual involved, not at the entire inpatient community. Asking for
medication will interfere with development of skills to manage angry feelings; medications may be used on an
as-needed basis if the client is losing control and at risk for injuring someone else.

Which goal is best for a married father of 3 children who tearfully explains that he feels
upset, embarrassed, and useless after losing his job?
Client will limit tearfulness
Client will increase his self-esteem
Client will control feelings of sadness
Client will promote acceptance by others
Rationale
The loss of a job can precipitate negative feelings about the self and decrease self-esteem. Feelings should be
expressed, not limited; attempts to decrease crying can make things worse. Crying is not necessarily an
expression of sadness; other feelings are involved. The focus should be on the client's self-acceptance, not
acceptance by others.

Which response is the most therapeutic to give to a client who has been sexually abused
and tearfully says, 'I'm no good now; there's nothing to live for'?
'Tell me more about your feelings.'
'I can understand why you feel worthless.'
'Why do you feel that there's nothing to live for?'

'Do you feel this way because of what has happened?'

Rationale
'Tell me more' encourages the exploration of feelings. 'You feel worthless' supports the negative feelings of
worthlessness. 'Why' questions are usually avoided. The client doesn’t always have insight into 'why,' but will
feel obligated to make up an answer to satisfy the nurse. Closed-ended questions that can be answered with a
yes or no do not encourage the exploration of feelings.

Test-Taking Tip: Pace yourself when taking practice quizzes. Because most nursing exams have specified time
limits, you should pace yourself during the practice testing period accordingly. It is helpful to estimate the
time that can be spent on each item and still complete the examination in the allotted time. You can obtain
this figure by dividing the testing time by the number of items on the test. For example, a 1-hour (60-minute)
testing period with 50 items averages 1.2 minutes per question. The NCLEX-RN® exam is not a timed test.
Both the number of questions and the time to complete the test vary according to each candidate's
performance. However, if the test taker uses the maximum of 5 hours to answer the maximum of 265
questions, each question equals 1.3 minutes.

Which crisis intervention is the most effective for a female client who cannot function
because of an impending divorce?
Limiting her support system to promote independence
Assisting her in exploring new coping abilities
Helping her gain insight into precipitating factors

Developing an action plan to repair the marital relationship

Rationale
Crisis intervention is intended to restore equilibrium by helping the client develop new ways to cope and
assist with the exploration of available support systems. Limiting the circle of support, at this time, will
increase the client's vulnerability and precipitate feelings of abandonment. Insight into precipitating factors is
not part of crisis intervention. Talking about precipitation factors is therapeutic, but her perception may be
distorted, and long-term therapy may be needed to gain true insight. Repairing the marital relationship may
not be realistic; if the client expresses a desire to avoid a divorce, this could be denial. The nurse would
conduct additional assessment.
Which intervention would the nurse use to develop a trusting relationship with a disturbed
child who acts out?
Ask the child to talk about feelings related to the parents.
Implement one-on-one interactions every half hour.
Offer support and encourage safety during play activities.
Begin setting limits and explain the rules that must be followed.

Rationale
Offering support and encouraging safety during play activities sets a foundation for trust because it allows the
child to see that the nurse cares. Inquiring about the child's feelings about the parents is too threatening at
this stage of the relationship. Thirty minutes may be too long between interactions; shorter, more frequent
contact is better for establishing trust. Setting limits and explaining the rules is necessary, but trust should be
developed first.

A young college student smiles and angrily says, 'If my girlfriend’s pregnancy test is
positive, I'll drop out of school, marry her, and get a full-time job.' Which term would the
nurse use to document the client's verbal and nonverbal behaviors?
Double-bind message
Mixed message

False reassurance
 Incongruent message

Rationale
Although the client's facial expression suggests happiness, the client's tone of voice gives the message of
anger; the behaviors are incongruent. A double-bind message occurs when a person in power uses 2 or more
contradictory statements or behaviors; the receiver is trapped in a no-win situation. The student is giving a
mixed message, but for documentation purposes, incongruent is the preferred term and in this case is more
precise. False reassurance occurs when a speaker tells a distressed person that everything will be okay, when
the outcomes are not guaranteed.

Which approach would the nurse use to evaluate a newly admitted depressed client’s
potential for suicide?
Questioning the client about plans for the future
Inquiring whether the client is now considering suicide

Discussing suicide with other clients while the client is in the group
Asking family members whether the client has ever attempted suicide

Rationale
The nurse would inquire whether the client is now considering suicide. Directness is the best approach at the
first interview, because this sets the focus and concern and lets the nurse know what the client is feeling now.
At this point, the client is most likely unable to think past the present, much less deal with future plans.
Discussing suicide with other clients while the client is in the group is an indirect approach, but initially the
direct approach is best. Asking family members whether the client has ever attempted suicide is one resource
for input, but with regard to suicide it is best to approach the client directly.

Which response would the nurse make to a depressed client who says, 'Go talk to someone
else. Other people need you more,' when the nurse states that they will be spending time
together?
'Why do you want me to go?'
'I’ll go, but I’ll be back tomorrow.'
'Don’t you think that you’re important, too?'
'I’ll be spending the next half hour with you.'

Rationale
The nurse would say, 'I’ll be spending the next half hour with you.' The nurse who spends time with the client
conveys a feeling of acceptance and helps build the client’s self-esteem. The response, 'Why do you want me
to go?' places the client on the defensive and does not respond to the feelings of worthlessness
communicated by the client, and the use of 'why' is avoided. The response, 'I’ll go, but I’ll be back tomorrow,'
implies agreement with the client’s implied statement that the client is not worthy; the nurse would stay to
convey a sense of worth to the client. The response, 'Don’t you think that you’re important, too?' may be too
direct and may precipitate a 'no' in reply. The client will respond better to actions than to words.

Which action would the nurse take when the language of a client in the manic phase of a
bipolar disorder becomes vulgar and profane?
State, 'We don’t like that kind of talk around here.'
Ignore it because the client is using it to gain attention.

Recognize that the behavior is part of the illness, but set limits on it.
Respond, 'We’ll talk with you when you can speak in an acceptable way.'

Rationale
Recognizing the language as part of the illness makes it easier to tolerate, but limits must be set for the
benefit of the staff and other clients. Setting limits also shows the client that the nurse cares enough to stop
the behavior. 'We don’t like that kind of talk around here,' shows little understanding or tolerance of the
illness. Ignoring the behavior is a form of rejection; the client is not using the behavior for attention. Saying,
'We’ll talk with you when you can speak in an acceptable way,' demonstrates rejection of the client and little
understanding of the illness.

A school-aged child is brought to the clinic by the parent, who states, 'Something is wrong.
My child never seems happy and refuses to play.' When assessing this child for depressed
behavior, with which response would the nurse initially begin?
'Tell me about yourself.'
'Let’s talk about what you do after school.'
'Can you tell me what’s making you so unhappy?'
 'Why does your mother think that you’re unhappy?'

Rationale
The nurse would say, 'Let’s talk about what you do after school.' A structured but nonthreatening question
such as asking what the child does after school avoids beginning with the problem and may put the child at
some ease, producing information that may be useful. The statement 'Tell me about yourself,' is too open and
global; the child will probably not know how to answer this question or know where to begin. The child may
not know the answer to the question, 'Can you tell me what’s making you so unhappy?' Asking, 'Why does
your mother think that you’re unhappy?' will probably produce an 'I don’t know' response; the focus should be
on the child, not the mother. Further, the use of 'why' should be avoided.

Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no
pattern to the answers.

Which response would the emergency department nurse say when assessing the
adolescent’s suicide potential after a drug overdose?
'Did you take pills because you wanted to kill yourself?'
'Do you know how much harm you can cause by taking these pills?'

'Lots of adolescents take too many pills because they want people to pay attention to them.'
'A few pills aren’t very much, but you seem to be asking for someone to pay attention to you.'
Rationale
The response, 'Did you take pills because you wanted to kill yourself?' brings the question of a suicide attempt
out into the open without judgment and allows the client to begin talking about it. Although it is a closed-
question, this is appropriate in an emergency situation and when information is needed quickly. The
response, 'Do you know how much harm you can cause by taking these pills?' is judgmental; it blames the
client for the behavior. The responses, 'Lots of adolescents take too many pills because they want people to pay
attention to them,' and 'A few pills aren’t very much, but you seem to be asking for someone to pay attention
to you,' negate the suicide intent and focus on attention-seeking behavior.

Which action would the nurse take to establish trust in a depressed client?
Spend a day with the client.
Ask the client at least 1 question daily.
Wait for the client to initiate the conversation.

Visit frequently for short periods with the client each day.

Rationale
Frequent short visits with the client each day demonstrate to the client that the nurse feels that the client is
worth spending time with and helps restore and build trust. Spending a day with a depressed client may be
overwhelming for the client, causing more withdrawal. Asking the client at least 1 question a day will do little
to establish communication between the nurse and the client and may be seen as threatening. The depressed
client may never initiate a conversation with the nurse and, left alone, will withdraw even further.

Test-Taking Tip: Do not select answers that contain exceptions to the general rule, controversial material, or
degrading responses.

When a client is expressing severe anxiety by sobbing in the fetal position on the bed, which
action would be the nurse’s priority?
Ensuring a safe therapeutic milieu
Monitoring and documenting vital signs
Eliminating the cause of the client’s anxiety
Providing an intense therapy session

Rationale
The nurse’s priority is ensuring a safe therapeutic milieu. Client safety is the nurse’s first priority, and because
the client has not experienced any physical injuries and is not at risk, attention should be directed toward
psychiatric risk, in this case crisis control. The severely stressed individual is likely to experience increased vital
signs but this is not the priority. During a psychological crisis, vital signs do not have to be taken unless
physical symptoms develop. Eliminating the cause of the client’s anxiety is highly unlikely; not all stress can be
eliminated. The client will not be able to concentrate on intense therapy until the crisis has been managed.

Which response would the nurse make to a depressed client who cries when the family does
not visit?
'It’s difficult to realize that no one cares about you.'
 'Your family didn’t visit, and now you’re feeling rejected.'
'It’s terrible to have such negative thoughts about yourself.'
'Your family members work—that’s why they don’t visit you.'

Rationale
The statement 'Your family didn’t visit, and now you’re feeling rejected' accurately reflects the client’s emotions
and may encourage exploration of feelings. The nurse does not know that no one cares about the client, and
the statement may increase the client’s unhappiness. The client is upset about the lack of visitors; discussing
negative self-thoughts changes the subject. The defensive statement 'Your family members work—that’s why
they don’t visit you' may worsen the client’s self-derogatory feelings and belittles the client’s feelings.

Test-Taking Tip: Do not read too much into the question or worry that it is a 'trick.' If you have nursing
experience, ask yourself how a classmate who is inexperienced would answer this question from only the
information provided in the textbooks or given in the lectures.

Which action would the nurse take for a deeply depressed, withdrawn client who remains
curled up in bed and refuses to talk to the nurse?
Sit with the client for set periods.

Touch the client gently on the arm when the opportunity arises.
Urge the client to participate in simple games with other clients.
Inform the client that going to the lounge is required in the daytime.
Rationale
Sitting quietly for set periods with a severely withdrawn client can provide an opportunity for nonthreatening
interaction. Entering a withdrawn client’s body space by touching the client’s arm is intrusive and stressful; it
often precipitates a need for further withdrawal. The client is unable to socialize with others at this time, so a
simple game with other clients is inappropriate. Placing demands on the withdrawn client by requiring the
client to go to the lounge causes a sense of threat, increased anxiety, and a need for additional withdrawal.

Which action would be effective in facilitating interaction between 2 depressed clients who
share a room?
Taking them to a unit bingo game together
Putting a puzzle together with them in their room
Exploring their reluctance to engage in conversation
Suggesting that they watch television together in their room

Rationale
Helping the clients work on a puzzle in their room provides an opportunity for interaction. This is a
noncompetitive activity that requires both interaction and some degree of cooperation. Taking the clients to a
bingo game gets them out of their room but does not facilitate interaction. Discussing their reluctance to
converse will do little to facilitate mutual interaction. Watching television does not foster social interaction.

Which activity would be therapeutic for a client who was recently diagnosed with bipolar I
disorder, manic episode?
 Doing a craft project

Playing a game of table tennis

Playing cards with another client
Walking around the unit with a nurse

Rationale
Walking around the unit with the nurse would be the appropriate activity. Walking allows the client to burn
excess energy in a safe, acceptable activity. A one-on-one activity demonstrates that the nurse cares and may
allow the nurse to verbally interact with the client. A quiet activity such as a craft project for a person who is
hyperactive is unrealistic and would be frustrating for the client. A game of table tennis would be too
stimulating and competitive, both of which may increase anxiety. A hyperactive client does not have the ability
to be quiet and focus on a card game.

Which nursing approach would encourage a socially withdrawn client to talk?

Focusing on nonthreatening subjects
Trying to get the client to discuss feelings
Asking simple yes-or-no questions of the client
Sitting quietly while looking through magazines with the client
Rationale
The nursing approach is focusing on nonthreatening subjects. The focus is to get the client to talk. Nursing
care involves a steady attempt to draw the client into some response. This can best be accomplished by
focusing on nonthreatening subjects that do not demand a specific response. The client is not ready yet to
discuss feelings; the first step is to focus on nonthreatening subjects. Yes-or-no questions do not encourage
communication. By sitting quietly with the client the nurse is showing acceptance of the client but doing
nothing to encourage communication.

Which response would the nurse make to a clinically depressed, tearful client who used
embroidery scissors to cut wrists?
Note the client’s behavior, record it, and notify the primary health care provider.
Sit quietly next to the client and wait until the client begins to speak.
Say, 'You’re crying. I guess that means you feel bad about attempting suicide and really want to live.'

Comment, 'I notice that you seem sad. Tell me what it’s like for you and perhaps we can begin to work
it out together.'

Rationale
The nurse would comment, 'I notice that you seem sad. Tell me what it’s like for you and perhaps we can
begin to work it out together.' Noting that the client seems sad and asking for a description of the feelings so
the nurse and client can begin to work it out together recognizes feelings and behavior; it encourages the
client to share feelings and it promotes trust, which is essential for a therapeutic relationship. Although
noting, recording, and notifying the primary health care provider of the client’s behavior are important
actions, they are not enough; nursing interventions with the client must be included. Without verbal
encouragement, the depressed client will not respond to the nurse sitting quietly and waiting. Saying that
crying means the client must feel bad about attempting suicide and really wants to live assumes too much
and may be inaccurate; an indirect approach would be used.

Which statements accurately describe nortriptyline? Select all that apply. One, some, or all
responses may be correct.
Overdosage is often lethal.

Constipation and urinary retention may occur.

It is a selective serotonin reuptake inhibitor (SSRI).
Weight gain is a common side effect.
It increases effectiveness of monoamine oxidase inhibitors (MAOIs).

Rationale
Nortriptyline can cause constipation and urinary retention because it causes blockage of cholinergic receptors,
and it tends to increase appetite and cause weight gain. Nortriptyline is notoriously lethal; between 70% and
80% of people who die from overdose do so before reaching the hospital. Nortriptyline is not an SSRI; it is a
tricyclic antidepressant and affects the balance of neurotransmitters in the brain. The interaction between
nortriptyline and MAOIs is severe and possibly fatal.

Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong
answer.
Which supervised activity would be therapeutic for a client with bipolar disorder, manic
episode, during the early phase of treatment?
Doing a needlepoint project
Joining a brief swimming competition

Walking around the facility with a nurse

Playing a board game with another client

Rationale
Walking around the facility with a nurse does not involve an element of competition and still allows the client
to channel excess energy safely. A needlepoint project requires fine motor skills of a client who is hyperactive
and whose attention span is limited. The sense of competition and added stimulation provided by a
swimming competition may increase the client’s anxiety and acting-out behavior. The client is too hyperactive
to play a board game and may respond with distractibility or aggressiveness toward others.

Which response would the nurse make during the last interview before discharge, when the
client who has follow-up therapy sessions says, 'There are a few things that bother me that
I’ve told no one'?
'The purpose of our getting together is to discuss your problems.'
'Do you want to work on those during the few minutes we have left?'
'What kind of problems have you not shared with me during our time together?'
 'One purpose of continuing counseling is to allow you to discuss things that bother you.'

Rationale
Clients may introduce new topics during the last session to prevent termination; the nurse would encourage
them to discuss these problems as outpatients in the follow-up therapy sessions. Two purposes of the last
interview are to summarize and terminate, not to begin discussion of new problems. The last minutes of the
last interview are not the appropriate time to introduce new problems; therefore, the responses, 'Do you want
to work on those during the few minutes we have left?' and 'What kind of problems have you not shared with
me during our time together?' are not appropriate.

Which nursing intervention would the nurse implement for a client with bipolar I disorder,
manic episode, who is attempting to organize the other clients in the lounge to form a
softball team?
Taking the client for a walk
Suggesting a time-out in the client’s room
Having the client play cards with another client
Explaining that there is no place for the clients to play a team sport

Rationale
Taking the client for a walk is a distraction and permits controlled expenditure of energy without affecting
others. Suggesting a time-out in the client’s room is punitive, and the client may react with increased activity
and acting out. The hyperactive client is unable to sit still long enough to play cards, and the activity will not
permit expenditure of excess energy. Logic will not necessarily interrupt the behavior in a manic client; the
nursing intervention needs to be more concrete.

Which response would the nurse make to a client who has been acting out for several weeks
and says, 'I’m really sorry about how I’ve acted. I’ll bet everyone thinks I’m an idiot'?
'You’re wondering how others will react to you now.'
'Some clients are concerned that you might lose control again.'
'Everyone feels foolish sometimes; you didn’t deliberately act that way.'

'Nobody thinks you’re a fool; everyone recognized that you were really struggling to keep control.'

Rationale
The nurse would reply, 'You’re wondering how others will react to you now.' Observing that the client is
worried about the perception of the other clients best clarifies the client’s major concern and encourages
discussion of feelings. The nurse cannot legitimately speak for other clients; saying what other clients are
thinking may increase the client’s anxiety about the future. Saying that everyone feels foolish sometimes is an
ineffective use of empathy, because it cuts off further communication; it also indicates that the nurse agrees
that the client acted foolishly. Saying that everyone realized that the client was struggling is inappropriate,
because the nurse cannot legitimately speak for other staff members and clients.
During the admission process, which approach would the nurse take for a client with
symptoms of manic behavior who has pressured speech punctuated with profanity?
Explaining in detail the type of behavior allowed in the facility
Stating that the use of profanity is inappropriate behavior
Interrupting the interview until the client refrains from using profanity
Encouraging the client to keep talking while using a nonjudgmental attitude

Rationale
The nurse would state that the use of profanity is inappropriate behavior. Setting limits on acting-out behavior
may prevent an escalation of anger that may result in harm to the client or others. Detailed explanations are
not helpful because the client’s easy distractibility interferes with understanding. Interrupting the interview
without setting limits on the behavior will be ineffective. Clients with pressured speech do not need
encouragement to talk. The nurse would be nonjudgmental but must also set limits on inappropriate
language and behavior to provide needed structure and feedback.

Which information would be most important for the nurse to emphasize when discussing
electroconvulsive therapy with the client who continues to express anxiety about the
procedure?
'The procedure may cause a headache.'
'The procedure will make you feel better.'

'You won’t be left alone during the procedure.'

 'You may have periods of amnesia after the procedure.'

Rationale
The most important response is 'You won’t be left alone during the procedure.' The staff ’s presence provides
continued emotional support and helps relieve anxiety. Although the client should be aware that headache
may occur, it is not the priority information that should be discussed with the client who continues to be
anxious. Also, a mild analgesic will be prescribed if a headache occurs. Although treatments may make the
client feel better, this is not the focus; the focus would be on the continued anxiety. Not all clients experience
amnesia, and the amnesia is temporary; placing emphasis on amnesia will increase fear. The most important
aspect is that the client continues to be anxious, indicating emotional support is needed, not education about
memory loss.

Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel insecure about a question,
eliminate the alternatives that you believe are definitely incorrect, and reread the information given to make
sure you understand the intent of the question. This approach increases your chances of randomly selecting
the correct answer or getting a clearer understanding of what is being asked. Although there is no penalty for
guessing, the subsequent question will be based, to an extent, on the response you give to the question at
hand; that is, if you answer a question incorrectly, the computer will adapt the next question accordingly based
on your knowledge and skill performance on the examination up to that point.

Which client behavior would the nurse anticipate after a client with bulimia nervosa eats 2
sandwiches, 2 salads, and 4 desserts for lunch?
Exercising excessively
 Hoarding of more food for a later binge
Active socializing with small groups of clients
Withdrawing from the group to go to the bathroom

Rationale
The nurse would anticipate the client withdrawing from the group to go to the bathroom. Bulimia is
characterized by the binge–purge cycle; most clients withdraw from others and vomit after an eating binge.
Although some individuals with bulimia may exercise to excess, this is a more common finding with the
diagnosis of anorexia nervosa. Although individuals with bulimia may hoard food, this behavior commonly
occurs later, when limits are put on their intake. Most individuals with bulimia do not seek support or
socialization after a binge, although they may socialize at other times.

STUDY TIP: Record the information you find to be most difficult to remember on 3-inch × 5-inch cards and
carry them with you in your pocket or purse. When you are waiting in traffic or for an appointment, just pull
out the cards and review again. This 'found' time may add points to your test scores that you have lost in the
past.

The mother who has been separated from her spouse for 6 months reports that her 7-year-
old child is falling behind in schoolwork and often cries. Which conclusion about the child
would the nurse consider?
Is feeling different from classmates

May be happier living with the other parent

 Is working through feelings of shame
May be experiencing self-blame for the parents’ breakup

Rationale
The child may be experiencing self-blame for the parents’ breakup. Young children usually blame themselves
for their parents’ marital problems, believing that they are the reason that a parent leaves. No data are
presented to indicate that the child feels different from peers, that the child will be happier living with the
other parent, or that the child is working through feelings of shame.

Which conclusion would the nurse make about a depressed, suicidal client who greets the
nurse cheerfully and states, 'Everything is looking up. I’m not going to have problems for
very long'?
Increased risk of suicide
Elevated level of anxiety

Positive response to treatment

Resolution of suicidal ideation

Rationale
A sudden lifting of mood may indicate an increased risk for suicide; the client may now have the emotional
energy to make the decision to act on suicidal ideas or, having decided to commit suicide, feels that the
problems will soon be gone. The anxiety level usually decreases when the client makes a decision; this may
indicate that the decision is to commit suicide. The client’s statement 'I’m not going to have problems for very
long' may indicate continuing suicidal thoughts, not a positive response to treatment or resolution of suicidal
ideation.

Which activity would the nurse suggest for a client with bipolar disorder who has
accelerating manic behavior?
Involving the client in a video game
Encouraging the client to join in group activities
Isolating the client away from others until the agitation lessens

Engaging the client in conversation while walking slowly in the hall

Rationale
The nurse would engage the client in conversation while walking slowly in the hall. Walking will help the client
discharge energy; by slowing the pace, the nurse may slow the client’s hyperactivity from the accelerating
manic behavior. A video game is too stimulating and may worsen the client’s hyperactivity. Group activities are
too stimulating for this client and may worsen the hyperactivity. Isolating the client is too restrictive and is
also punitive because there is an inability for the client to relieve the excess hyperactivity.

STUDY TIP: Remember that intelligence plays a vital role in your ability to learn. However, being smart
involves more than just intelligence. Being practical and applying common sense are also part of the learning
experience.
Which rationale would support the nurse’s decision to encourage involvement with unit
activities for a client whose depression is beginning to lift?
Unit activities support self-confidence.
Unit activities provide for group interaction.
Unit activities limit opportunities for anxiety.
Unit activities allow verbalization of repressed hostility.

Rationale
Unit activities provide for group interaction, which, in turn, provides a sense of belonging and fosters the
assumption of responsibility. Support of self-confidence is not ensured by group interaction. In the beginning,
anxiety may be increased for a depressed client attending unit activities. The group is not the best arena for
the expression of repressed hostility.

Which statement by the client who has major depressive disorder would alert the nurse to
the possibility of a suicide attempt?
'I don’t feel too good today.'

'I feel much better; today is a lovely day.'

'I am a little better, but it probably won’t last.'
'I’m really tired today, so I’ll take things a little slower.'
Rationale
The response, 'I feel much better; today is a lovely day,' would alert the nurse to a possibility of suicide. A rapid
mood upswing and psychomotor change may signal that the client has made a decision and has developed a
plan for suicide. 'I don’t feel too good today,' 'I am a little better, but it probably won’t last,' and 'I’m really tired
today, so I’ll take things a little slower' are all typical of the depressed client; none of these statements signals a
change in mood.

Which response would the nurse make to a hospitalized older depressed client who tells the
nurse that life is no longer worth living?
'Why do you want to die?'

'Are you having thoughts about suicide?'

'You must be very depressed to feel that way.'
'Let’s focus on something positive in your life.'

Rationale
The nurse would ask, 'Are you having thoughts about suicide?' Asking direct questions about suicidal intent
helps the client verbalize, because it demonstrates to the client that the topic is one that can be discussed. It
also provides essential information needed to plan care. Using the word 'why' is nontherapeutic and should be
avoided. Asking the client the reason for wanting to die is not the priority; the client has already said that life is
not worth living and may not be able to elaborate further. Stating that the client must be very depressed is
judgmental and may put the client on the defensive and block communication. By moving the focus to
finding something positive to talk about, the nurse is avoiding discussing the issue; this statement may block
further communication.

Which intervention would the nurse implement for a client who is confused and delirious?
Reassuring the client that it will get better
Directing the client’s daily activities on the unit
Helping the client gain insight into personal behavior

Providing the client with solutions to past and current problems

Rationale
The nurse would direct the client’s daily activities on the unit. The client needs to have activities decided and
directed until delirium and confusion clear. Reassuring the client that it will get better is false reassurance.
Clients who are delirious are unable to develop insight into their behavior. Providing the client with solutions
to past and current problems experienced is not therapeutic for a client with delirium and does not help the
client develop insight.

Which response would the nurse make to a depressed older client who has not been eating
well since admission to the hospital and repeatedly states, 'No one cares'?
'We all care about you; now please eat.'

'We all care about you; you have to eat to stay alive.'
'I care about you. What are some foods you especially like?'
 'I care about you. Will you please eat some of this food for me?'

Rationale
The nurse would make the statement, 'I care about you. What are some foods you especially like?' This is a
direct response to the client’s concern and permits some exploration of food choices. The nurse would not talk
for others by saying, 'we all care about you' and would not patronize the client by saying, 'now please eat.' 'We
all care about you; you have to eat to stay alive,' belittles the client’s feelings. 'I care about you. Will you please
eat some of this food for me?' encourages dependence on the nurse; the message is 'Do it for me, not because
it is important for you.'

Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an educated guess on
your part, go ahead and mark an answer. You might be right, but if you leave it blank, you will certainly be
wrong and lose precious points.

Which interpretation would the nurse make about a depressed client with mild suicidal
ideation who has no plan, but has adequate family support and attends church regularly?
Should be at no risk for suicide
Warrants one-on-one observation

Warrants placement in a seclusion room

Should be reassessed at intervals regarding suicidal intent
Rationale
The nurse would make the interpretation that the client should be reassessed at intervals regarding suicidal
intent. Although this client is at risk for suicide and should be reassessed frequently, because the client has a
support system and no plan, the risk is not as great as for someone with no support and a plan. Any client
who has suicidal ideas is at risk for suicide, whether or not there is a plan, but a person with a plan is at a
higher risk than a person without a plan. This client has no immediate plan and no history of suicide
attempts; therefore, one-on-one observation is not indicated. A seclusion room is a last resort when a client is
out of control and at risk for injuring others.

Test-Taking Tip: The most reliable way to ensure that you select the correct response to a multiple-choice
question is to recall it. Depend on your learning and memory to furnish the answer to the question. To do
this, read the stem, and then stop! Do not look at the response options yet. Try to recall what you know and,
based on this, what you would give as the answer. After you have taken a few seconds to do this, then look at
all of the choices and select the one that most nearly matches the answer you recalled. It is important that you
consider all the choices and not just choose the first option that seems to fit the answer you recall. Remember
the distractors. The second choice may look okay, but the fourth choice may be worded in a way that makes it
a slightly better choice. If you do not weigh all the choices, you are not maximizing your chances of correctly
answering each question.

Which response would the nurse make to a depressed client who was forced into early
retirement and reports feeling useless and having nothing to do?
'Tell me more about feeling useless.'

'Volunteering can help you fill your time.'

'Your illness is adding to your current feelings.'
 'Let’s talk about what you’d like to be doing right now.'

Rationale
The nurse would say, 'Tell me more about feeling useless.' An open-ended response encourages further
discussion and allows exploration of feelings. Telling the client that volunteering will help pass the time
ignores the client’s feelings and is giving advice. The depression is not adding to the feelings; the feelings are
causing the depression. Asking the client to talk about what the client would rather be doing ignores the
client’s feelings and changes the subject.

Which action would the nurse take for a client with bipolar I disorder, manic episode?
Provide a quiet atmosphere by placing the client in a private room.
Ensure a cheerful environment by having bright drapes in the client’s room.

Promote access to activities by assigning the client to a room near the dayroom.
Encourage interaction with others by having the client share a room with other clients.

Rationale
The nurse would provide a quiet atmosphere by placing the client in a private room. The excited, overactive
client needs a calm environment; external stimulation causes further excitation. The nurse would provide a
quiet atmosphere by placing the client in a private room. Bright drapes will provide too much stimulation to a
client with mania. A room near the dayroom is too active for a client with mania. Encouraging interaction by
having the client share a room is not an appropriate intervention because it could increase the mania and be
detrimental to the assigned roommate.

Which action would the nurse take for a client with bipolar disorder, manic episode, who
calls the nurse names, is sarcastic to the staff, and taps the nurse playfully on the buttocks?
Spend extra time with the client.
Place the client alone in a quiet room.
Disregard the client’s acting-out behavior.
Set limits for unacceptable behavior.

Rationale
The nurse would set limits for unacceptable behavior. The step the nurse would implement is setting limits to
maintain the client’s dignity and prevent escalation of inappropriate behavior. More aggressive interventions
may be necessary if this step is ineffective. Client and nurse safety is priority. Increasing the time spent with
the client will exaggerate problems for both the nurse and the client and rewards undesirable behavior.
Placing the client in isolation may appear punitive rather than therapeutic and is considered a type of restraint
which is strictly regulated and used as a last resort. Disregarding this type of behavior does not let the client
know boundaries are being crossed. The manic client will think these are acceptable behaviors if limits are not
set. The client needs external controls when these types of behaviors occur.

Test-Taking Tip: Be alert for grammatical inconsistencies. If the response is intended to complete the stem (an
incomplete sentence) but makes no grammatical sense to you, it might be a distractor rather than the correct
response. Question writers typically try to eliminate these inconsistencies.

Which response would the nurse make to a client with acute depression who says, 'God is
punishing me for my past sins'?
'Why do you think that?'
'You sound very upset about this.'
'Do you believe that God is punishing you for your sins?'

'If you feel this way, you should talk to your spiritual advisor.'

Rationale
The nurse would say, 'You sound very upset about this.' This response focuses on the client’s feelings rather
than the statement, and it serves to open channels of communication. 'Why do you think that?' asks the client
to decide what is causing the feelings; most people are unable to explain why they feel as they do and 'why'
should be avoided. 'Do you believe that God is punishing you for your sins?' simply echoes the client’s
statement and does not reflect feelings or stimulate further communication. 'If you feel this way, you should
talk to your spiritual advisor,' does nothing to stimulate further communication; in fact, it tells the client to
talk about the feelings with someone else.

Test-Taking Tip: Choose the best answer for questions asking for a single answer. More than one answer may
be correct, but one answer may contain more information or more important information than another
answer.
Which long-term outcome would be appropriate for a client with severe rheumatoid
arthritis who becomes depressed and is admitted to the psychiatric unit?
Eats at least 2 meals per day with other clients

Maintains self-care while attending structured activities

Makes a positive verbal comment to another client daily
Decreases negative thinking about self, others, and life

Rationale
The long-term outcome is to decrease negative thinking about self, other, and life. The long-term goal is that
the client attains a positive attitude about the self, others, and life in general; this indicates that treatment has
been effective and the client may be discharged. Eating at least 2 meals per day with other clients is a short-
term goal associated with a therapeutic milieu. Maintaining self-care while attending structured activities is a
short-term goal and an expected behavior on an inpatient unit. Making a positive verbal comment to another
client daily is an intermediate goal that helps the client focus on others; this goal is a step toward achieving
long-term goals.

Test-Taking Tip: Choose the best answer for questions asking for a single answer. More than one answer may
be correct, but one answer may contain more information or more important information than another
answer.

Which response would the nurse make to a client with bipolar I disorder, depressed episode
who is found lying on the floor by the bed and states, 'I don’t deserve a comfortable bed'?
 'Everyone has a bed. This one is yours.'
'You are not allowed to sleep on the floor.'

'I don’t understand why you’re on the floor.'

'You’re a valuable person. You don’t need to lie on the floor.'

Rationale
The nurse would say, 'Everyone has a bed. This one is yours.' A matter-of-fact approach helps prevent a cycle in
which the nurse expresses concern to a client who feels unworthy, which increases feelings of unworthiness.
Citing a hospital policy (You are not allowed to sleep on the floor) focuses on rules and regulations, which may
exacerbate the client’s negative personal feelings for breaking the rules. 'I don’t understand why you’re on the
floor,' is a statement that the client may not be able to respond to. Saying the client is a valuable person and
doesn’t need to lie on the floor may increase feelings of unworthiness, because it creates a gap between the
nurse’s estimate of the client and what the client feels.

Test-Taking Tip: Choose the best answer for questions asking for a single answer. More than one answer may
be correct, but one answer may contain more information or more important information than another
answer.

Which comment by the suicidal college student would indicate relief from suicidal
thinking?
'I can be a burden to others.'
'I feel very alone sometimes.'
 'I plan to go to school next semester.'

'I don’t know whether I can talk about my feelings.'

Rationale
The comment, 'I plan to go to school next semester,' would indicate relief from suicidal thinking. The suicidal
client cannot think about a positive future; therefore, focusing on the future indicates improvement. Feeling
like a burden to others reflects low self-esteem, which also increases the risk for suicide. Feeling alone reflects
a perceived lack of support, which increases the risk for suicide. Not being able to talk about feelings increases
the risk for suicide, because the client must be able to verbalize feelings to reduce anxiety, seek help, or
engage in therapy.

Which response would the nurse make to a client with bipolar I mood disorder, manic
episode, who says to the nurse, 'I don’t know what I’m doing here. I never felt better in my
life; I’ve got the world on a string around my finger'?
'Have you ever felt this way before?'

'You’re feeling pretty elated right now.'

'You have the whole world on a string.'
'Why do you think you’re feeling so good?'

Rationale
The nurse would make the response, 'You’re feeling pretty elated right now.' This response demonstrates
empathy; in addition, it focuses on the client’s feelings. The question, 'Have you ever felt this way before?' will
elicit a yes or no answer; an open-ended response allows for more self-expression. The response, 'You’ve got
the whole world on a string,' reflects only part of the content; it may be the least significant part of the client’s
statement. 'Why' questions should be avoided, because people often do not know why they feel or behave the
way they do; this question may cause defensiveness.

Which initial action would the nurse take for a manic client who is constantly cursing, using
foul language, and has the other clients on the unit terrified?
Demand that the client stops the behavior immediately.

Tell the client firmly that the behavior is unacceptable.

Ask the client to identify what is precipitating the behavior.

Increase the client’s medication or get a prescription for another medication.

Rationale
The initial action is to tell the client firmly that the behavior is unacceptable. A firm voice is most effective; the
statement tells the client that the behavior, not the client, is upsetting to others. Demanding that the client
stop the current behavior is a useless action; the client is out of control and needs external control. The client
does not know what is precipitating the behavior and asking the client will be frustrating. The client may need
an as-needed medication for short-term use, but this is not the initial action the nurse would take. This would
come later if limit setting does not work. The dosage of the client’s medication may need to be increased, but
this may only be done by the health care provider.
1 topics covered

Mood and Affect Intermediate

HESI Concept / Psychological

Novice Intermediate Proficient Questions

 
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