Question



QUESTION 1
discusses the patient’s immediate goals. Which patient outcome will the RN emphasize with the team?
a. The patient will interact appropriately with others.
b. The patient will sleep 8 hours per night without medication.
c. The patient will verbalize that hallucinations have decreased.
d. The patient will maintain a stable weight.

QUESTION 2
What must the RN consider when assessing cultural influences for individuals with mood disorders?
a. Substance abuse is more common in some cultures.
b. Immigrants tend to have more strong family support.
c. Emotions have different meaning in different cultures.
d. Firmly held religious beliefs often counteract mood perceptions.

QUESTION 3
Which action by the RN best demonstrates the ethical principle of beneficence as applied to a client with severe mental illness?
a. Determining how to ensure safety when the client refuses their medication.
b. Asking the client’s representative to give consent for a procedure.
c. Being honest about the client’s diagnosis, prognosis, and treatment.
d. Acting as an advocate for the client to secure essential mental-health services.

QUESTION 4
A client with an inappropriate affect disorder is being cared for by a team that includes an RN, an LPN, and a UAP. The RN explains to the team members that they may notice which of the following client behaviors when they are providing care?
a. Finding enjoyment in small things.
b. Crying when learning sad news.
c. Absence of a response to a situation.
d. Experiencing extreme pleasure.

QUESTION 5
The RN contacts the healthcare provider regarding a client’s sudden onset of symptoms of depression and learns that which medication may be responsible?
a. acetaminophen (Tylenol)
b. ethinyl estradiol/norethindrone (Ortho-Novum)
c. alprazolam (Xanax)
d. quinapril (Accupril)

QUESTION 6
Which topics will the RN include when teaching a client about the side effects associated with the use of Selective Serotonin Reuptake Inhibitors (SSRIs)?
a. Weight gain and blurry vision.
b. Hypotension and tachycardia.
c. Gastrointestinal distress and sexual dysfunction.
d. Cardiac dysrhythmias and seizures.

QUESTION 7
The RN should include which interventions in the plan of care for a client admitted to the mental health unit after an attempted suicide? Select all that apply.
a. Administer medications and watch the patient swallow them.
b. Provide one-to-one contact with the patient.
c. Make rounds at the same time every hour.
d. Insist on a verbal contract of no harm.
e. Orient the patient to reality.

QUESTION 8
Which assessment data supports the presence of acute delirium in a patient?
a. The cause is from irreversible disturbances in brain function.
b. Memory impairment onset is sudden.
c. Deterioration is consistent with some lucid moments.
d. Symptoms have been present for a few months.

QUESTION 9
The RN would be concerned about which food in the diet of a client admitted with toxic effects of a prescribed Selective Serotonin Reuptake Inhibitor (SSRI)?
a. Chocolate
b. Milk
c. Cheese
d. Grapefruit

QUESTION 10
The RN notes which assessment data are consistent with a patient experiencing Bipolar Disorder? Select all that apply.
a. Inappropriate sexual behavior.
b. Neat and clean groomed appearance.
c. Sleeping 8 hours per night.
d. Refusal to get dressed in the morning.
e. Excessive spending of money.

QUESTION 11
A client who has been taking clozapine for the past two months reports sudden onset of sore throat, fever, and malaise. Which data is most concerning to the RN?
Temperature of 101° F
White blood count of 3,000/mm3 Hematocrit of 46%
Pulse of 110

QUESTION 12
A hospitalized adolescent who was born anatomically male has the self-perception of being female Which of the following actions by the RN is most appropriate for this client?
a. Arrange for an Endocrine consultation.
b. Arrange for the Pastoral Care Department to visit.
c. Place the client with a female roommate.
d. Refer to the client using female pronouns.

QUESTION 13
Which nursing intervention is appropriate for a patient with the nursing diagnosis Impaired memory after returning from a military deployment where a head injury was sustained?

a. Report any noticeable cognitive changes to health care provider.
b. Assess for generalized twitching of extremities.
c. Teach about ways to improve attention span.
d. Assist with confusion when trying to formulate sentences.

QUESTION 14
An adult patient with no prior behavioral health history was involuntarily admitted to the mental health unit with a diagnosis of Bipolar Mania after the patient’s brother noticed recent episodes of wild spending sprees, shoplifting, and confrontations with authority figures. When the brother inquires as to what caused the problem, which is the appropriate response by the RN?
a. “The disorder is hereditary and, therefore, twins are also at risk.”
b. “Both biological and psychosocial factors are believed to be involved.”
c. “It is frequently triggered by excessive alcohol use.”
d. “The disorder is characterized by brain chemistry disturbances.”

QUESTION 15
When educating a client about ethnic and cultural factors that predispose a person to alcohol addiction, which of the following will the RN include?
a. Native-American heritage
b. Japanese heritage
c. Italian heritage
d. French heritage

QUESTION 16
A client in alcohol withdrawal has been prescribed lorazepam (Ativan) 2 mg IM, one stat dose. The pharmacy label reads: 0.5 ANSWER

QUESTION 17
Which is an appropriate outcome when caring for a client with delusions of persecution?
a. Reduction of symptoms.
b. Decrease in medication doses.
c. Function without medications.
d. Return to employment.

QUESTION 18
Which of the following would be an expected outcome for the nursing diagnosis Imbalanced nutrition: less than body requirements related to binging and purging?
a. Client will gain a prescribed amount of weight weekly.
b. Client will be able to identify foods and situations that are triggers.
c. Client will negotiate a contract for meals eaten.
d. Client will measure all portions carefully.

QUESTION 19
The RN asks an LPN to sit with a highly anxious client and engage in light conversation while admission paperwork is finalized. Which statement made by the LPN to the client and overheard by the RN is appropriate?
a. “You must be feeling pretty stressed right now.”
b. “You could use some anti-anxiety medication.”
c. “Everything will be all right, so try to relax.”
d. “I wouldn’t worry about that if I were you.”

QUESTION 20
The RN is developing a plan of care for a client with Schizophrenia who is experiencing visual hallucinations. What would be an expected short-term outcome for the nursing diagnosis of Anxiety related to unconscious conflict with reality?
a. The client will accept the anxiety in the presence of the hallucination with next occurrence.
b. The client will discuss the content of the hallucinations within one week.
c. The client will state the images can be stopped at any time.
d. The client will learn to use voice dismissal prior to discharge.

QUESTION 21
A hospitalized client who had been taking low-dose chlordiazepoxide as a sleep aid for several years has stopped this medication abruptly. The RN can expect to see withdrawal symptoms begin how long after cessation of the medication?
a. 3 days afterwards
b. 5-8 days afterwards
c. 2-4 hours afterwards
d. 12-24 hours afterwards

QUESTION 22
A 40-year-old client with new-onset Schizophrenia has been taking fluphenazine for four days and begins to exhibit symptoms of muscular weakness, which is an indication of:
a. Dystonia
b. Akinesia
c. Akathisia
d. Pseudoparkinsonism

QUESTION 23
Which of the following observations should make the RN suspect possible parental child abuse when assessing an 8-year-old child that was brought to the emergency room after a school sports injury?
a. Child starts crying, saying he wants to go home.
b. Child refuses to allow the nurse to examine him.
c. Child complains that his teammates are “mean.”
d. Child recoils when father enters the exam room.

QUESTION 24
Which RN intervention best supports a care plan based on Maslow’s physiological needs?
a. Initiating contact precautions.
b. Keeping the side rails up on the bed.
c. Involving the family in the plan of care.
d. Maintaining an oxygen saturation of 95%.

QUESTION 25
The RN is assessing a newly admitted client using the Michigan Alcoholism Screening Test (MAST). When the client responds affirmatively to the question, “Have you ever lost friends because of your drinking?”, the score of 5 is assigned by the RN. What does this indicate about the client’s use of alcoholic beverages?
a. The client has a possible problem with alcohol use.
b. The client previously had a problem with alcohol use, but is now recovered.
c. The client has no problems with alcohol use.
d. The client has a definite problem with alcohol use.

QUESTION 26
Which medication is contraindicated for adolescents who are being treated for major depressive disorder?
a. fluoxetine (Prozac)
b. escitalopram (Lexapro)
c. imipramine (Tofranil)
d. paroxetine (Paxil)

QUESTION 27
Which behavior would first alert the RN that a co-worker might be impaired due to substance abuse?
a. Preferring to eat alone during lunch.
b. Unexplained disappearance from the nursing unit.
c. Clients reporting unrelieved pain.
d. Discrepancies in the end-of-shift count.

QUESTION 28
Which side effect would the RN address when providing patient teaching for a client taking typical (traditional) antipsychotic medications?
a. Hyperactivity
b. Excessive energy
c. Dystonia
d. Urinary frequency

QUESTION 29
Which nursing interventions would be appropriate when providing care for a patient who is exhibiting symptoms of a panic attack? Select all that apply.
a. Instruct the patient to take slow deep breaths.
b. Encourage the patient to attend group therapy.
c. Loosen any restrictive clothing.
d. Decrease external stimuli and noise.
e. Increase the volume on the television to distract the patient.

QUESTION 30
Why would the RN ask a client about her use of St. John's Wort as an alternative treatment for Depression?
a. The cost of the treatment may be more than that of standard therapies.
b. It can interfere with the action and effectiveness of other medications.
c. A prescription is required to obtain it from a pharmacy.
d. Alternative medicines are not effective in the treatment of depression.

QUESTION 31
Which statement is accurate about the admission status of a client with a longstanding history of Depression who seeks admission for psychiatric treatment due to thoughts of self-harm?
a. The client must have a family member authorize the admission.
b. The client relinquishes all rights to have a say in treatment decisions.
c. By law, the maximum duration of this admission may only be 72 hours.
d. The client may leave the hospital at any time unless deemed a danger to self or others.

QUESTION 32
An LPN is assisting with the care of a client receiving an antipsychotic medication for the treatment of Schizophrenia. The RN tells the LPN to report immediately if which of the following client symptoms is noticed?
a. Excessive drooling of saliva.
b. Smacking of the lips.
c. Shouting of obscenities.
d. Tremors at rest.

QUESTION 33
Which nursing intervention would the RN include in the plan of care for an autistic client with the nursing diagnosis of Self-mutilation?
a. Set time limits for meals.
b. Maintain a structured schedule of daily activities.
c. Offer sympathy during episodes of self-mutilation.
d. Rotate staff members who care for the client.

QUESTION 34
The RN is conducting a 15-minute mental health assessment for a client in the manic phase of Bipolar Disorder. What is the rationale for limiting the length of the assessment?
a. Too many questions can lead to depression.
b. A longer period of time may overstimulate the client.
c. The client will feel pressured to keep talking.
d. The client will lose interest if it is longer.

QUESTION 35
The RN is aware that which would occur if needs were not met during the latency stage of Freud’s development?
a. Disorganization, untidiness and destructiveness.
b. Identification with the opposite-gender parent.
c. Inability to trust others.
d. Inability to develop relationships with other children.

QUESTION 36
Which clinical manifestation will the RN expect to observe in a patient taking the medication disulfiram (Antabuse) who presents to the emergency room where a blood alcohol level of 125 mg/dL is obtained?
a. Nausea and vomiting
b. Sweating
c. Headache
d. Heart failure

QUESTION 37
Which behavior would the RN interpret as an inappropriate affect?
a. Smiling when receiving news of a birth of a child.
b. Crying when being told that the family pet has died.
c. Reacting calmly when a child drops food on the floor.
d. Giggling while reading the news of a fatal car accident.

QUESTION 38
Which RN intervention is the priority when caring for a patient with Borderline Personality Disorder who displays occasional self-destructive behaviors?
a. Place the patient under continuous observation.
b. Minimize physical activity to discourage violent impulses.
c. Encourage the patient to explore triggers for the behaviors.
d. Contact the healthcare provider for an order for restraints.

QUESTION 39
To create a safe environment for a client with Alzheimer’s disease who wanders, the RN instructs the LPN to assist with which of the following interventions?
a. Encourage independence with preparing meals.
b. Provide an enclosed area for pacing.
c. Remove all diversions such as television and radio.
d. Maintain a varied schedule for meals and toileting.

QUESTION 40
Which nursing interventions are important for the RN to incorporate into a care plan for a client with an Obsessive-Compulsive Disorder? Select all that apply.
a. Tell the patient to spend more time alone.
b. Involve the patient in group therapy activities.
c. Discourage physical activity as it might cause fatigue.
d. Encourage journaling to sort out feelings.
e. Teach the patient to breathe slowly and deeply.

Answer 1

1) b. The patient will sleep 8 hours per night without medication.When compared with other other option it is the most appropriate answer because immediate goals means acheiving goals in a short period of time.

2) c. Emotions have different meaning in differeent cultures.Nurses must be aware of impact their own culture ,emotins and values have on the care they provide and to avoid biases.Emotions are affected by the culture , clients with different culture have different emotions so while assessing the patient we need focus importance on this more.The other options are wrong.

3)d. Acting as an advocate for the client to secure essential mental health services.Cultural competency allows the nurse to recognize the uniquences of each client and the impact that culture ,values ,bele=iefs have on individual mental health as well as the treatment for existing mental illness.The other options are not appropriate.

4)c Absence of pleasure to a situation.In this condition patient experience experience happiness or sadnrss without any cause or they doesnot show any emotions to situation.