Diya Coaching Centre for Nurses

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Unit-18_Test-1_Answer

1. Correct Answer : 4
Rationale: A depressed person experiences a depressed mood and is often withdrawn. Also, the person
experiences difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of
worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a
stimulating yet structured environment. Options 1 and 2 provide little or no structure, and option 3 is a
forceful and absolute approach.

2. Correct Answer : 1
Rationale: The diagnosis of "major depression: recurrent with psychotic features" alerts the nurse that, in
addition to the criteria that designates the diagnosis of major depression, he or she also must deal with the
client's psychosis. Psychosis is defined as a state in which a person's mental capacity to recognize reality
and to communicate and relate to others is impaired; this obviously interferes with the person's capacity to
deal with life's demands. Altered thought processes generally indicate a state of increased anxiety, where
hallucinations and delusions prevail. Although all of the nursing diagnoses may be appropriate because the
client is experiencing psychosis, option 1 is the correct option.

3. Correct Answer : 4
Rationale: Clients who like to retell stories or past events need to be provided the opportunity to do so.
This phenomenon is called life review or reminiscence. In a sense, it is a way for the elder client to relive
and restructure life experiences, and is a part of achieving ego identity. Option 1 indicates reality
orientation techniques. Options 2 and 3 indicate socialization and physical activity.

4. Correct Answer : 4
Rationale: Option 4 describes aversion therapy. Options 1, 2, and 3 are characteristics of self control
therapy. Test-Taking Strategy: Use the process of elimination. Note the keyword not in the stem of the
question. Think about the issue self-control. This issue should easily direct you to option 4. If you are
unfamiliar with self-control therapy, review this content.

5. Correct Answer : 1
Rationale: Operant conditioning entails rewarding a client for desired behaviors and is the basis for
behavior modification. It uses a positive reinforcement approach. Options 2, 3, and 4 are accurate
characteristics of this form of therapy.

6. Correct Answer : 2
Rationale: Finding the right medication at the right dose that provides the fewest side effects for the
client, providing clients with the injectable, long-acting form of the medication, and including the family in
the medication planning process are measures that will promote compliance. Not all medications can be
given on a once per day dosing regimen because of their short half-life.

7. Correct Answer : 1
Rationale: Tricyclic antidepressants can be fatal when taken as an overdose regardless of the amount
ingested. Serious, life-threatening symptoms can develop after an overdose. Immediate emergency medical
attention and cardiac monitoring is necessary with an overdose of tricyclics.

8. Correct Answer : 2
Rationale: The client should be placed in a room near the nurses ' station and not at the end of a long,
rela-tively unprotected corridor. The nurse should not isolate self with a potentially violent client. The door
to the client's room should be kept open and the nurse should never turn away from the client. A security
officer should be within immediate call should a suspicion of violence is imminent.

9. Correct Answer : 4

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Rationale: A crisis is an acute time-limited state of disequilibrium resulting from situational,

developmental, or societal sources of stress. A person in this state is temporarily unable to cope with or
adapt to the stressor by using previous coping mechanisms. One who intervenes in this situation (the nurse)
"takes over" for the client who is not in control and devises a plan (action) to secure and maintain the
client's safety. Once this has occurred, the nurse works collaboratively with the client (participates) in
developing new coping and problem-solving strategies.

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10. Correct Answer : 3

Rationale: This client is in a severe state of anxiety. When a client is in a severe or panic state of
anxiety, it is critical for the nurse to remain with the client. Processing the anxiety at this point will further
increase the client's level of anxiety. The client in a severe state of anxiety would not be able to learn
relaxation techniques.

11. Correct Answer : 2

Rationale: The client who has severe anxiety has significant somatic complaints, ineffective
functioning, loud or rapid speech, and purposeless activity. The client symptoms in the question do not
relate to options 1, 3, and 4.

12. Correct Answer : 4

Rationale: Ineffective individual coping may be evidenced by inability to meet basic needs, inability to
meet role expectations, alteration in social participation, use of inappropriate defense mechanisms, or
impairment of usual patterns of communication. Altered thought processes is evidenced by altered
attention span, distractibility or disorientation to time, place, person, and events. Altered family process
may exist when the family has difficulty adapting or responding to the changes or traumatic experience of
the member in crisis.

13. Correct Answer : 3

Rationale: The initial nursing assessment of a client in a crisis state is to evaluate the physical condition
of the client, the potential for self-harm, and the potential for harm to others. Once this has been
determined and appropriate interventions have been initiated, the nurse would then proceed with the
mental health interview.

14. Correct Answer : 4

Rationale: The client presents a lethality potential if the client appears disorganized and impulsive.
Clients at higher risk include those with a history of a dual diagnosis of mental illness and substance abuse,
a personal or family history of suicide attempts, depression, alcoholism, or psychotic episodes. Having a
plan, particularly if the method is immediate and available, makes the client a very high risk.

15. Correct Answer : 2

Rationale: The client is experiencing loss and is feeling hopeless. The most therapeutic response by the
nurse is the one that attempts to translate words into feelings. In option 1, the nurse is voicing doubt. In
option 3, the nurse is disagreeing with client, which implies that the nurse has passed judgment on the
client's ideas or opinions. In option 4, the nurse uses sarcasm that gives advice and is nontherapeutic as a
nursing response.

16. Correct Answer : 4

Rationale: The sudden change in the depressed client's mood and affect may indicate that the client has
come to a decision about suicide. The only way to be sure is to ask the client directly. Option 1 assumes a
meaning of the behavior. Option 2 offers no different strategy than would be used with any client.
Notifying others of your concern does nothing to address the problem directly.

17. Correct Answer : 1

Rationale: Exercising 3 to 4 hours every day is excessive physical activity and unrealistic for a sixteen-
year-old. The nurse needs to further assess this statement immediately to find out why the client feels the
need to exercise this much to maintain her figure. Although it's unfortunate that her best friend had this
disease, it is not considered a major threat to this client's physical well-being. A weight that exceeds 15
below the ideal weight is most significant with anorexia nervosa. It is not considered abnormal to check
weight every day. Many clients with anorexia nervosa check their weight close to 20 times a day.

18. Correct Answer : 2

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Rationale: In the termination phase of a relationship, it is normal for a client to demonstrate a number of
regressive behaviors that can be disturbing to the nurse. Typical behaviors include return of symptoms,
anger, withdrawal, and minimizing the relationship. The anger that the client is experiencing is a normal
behavior during the termination phase and does not necessarily indicate the need for hospitalization or
treatment.

19. Correct Answer : 1

Rationale: Cognitive behavioral therapy is used to help clients to identify and examine dysfunctional
thoughts as well as to identify and examine values and beliefs that maintain these thoughts. Options 2, 3,
and 4 are incorrect.

20. Correct Answer : 4

Rationale Reminiscence therapy is best for clients who meet the following criteria: normal to mild
cognitive impairment; mild to moderate depression; withdrawn, socially isolated, understimulated
behavior.

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21. Correct Answer : 1

Rationale: Cognitive therapy is frequently used with clients who have depression. This type of therapy is
based on exploring the client's subjective experience. It includes examining the client's thoughts and
feelings about situations as well as how these thoughts and feelings contribute to and perpetuate the client's
difficulties and mood.

22. Correct Answer : 2

Rationale: An open discussion about suicide will not encourage a client to make a decision to commit it;
in fact, such a discussion will often help to prevent it. This type of discussion offers the health care
professional the opportunity to assess the possibility of suicide for the client and to take necessary
precautions to keep the client safe. Options 1, 3, and 4 are inaccurate statements about suicide.

23. Correct Answer : 3

Rationale: The individual at highest risk for suicide is the individual with terminal illness. Other high-
risk groups include adolescents; drug abusers; those individuals with social problems, recent losses, and
few or no social supports; and individuals with a history of suicide attempts and a suicide plan.

24. Correct Answer : 4

Rationale: Personal characteristics of abusers include low self-esteem, immaturity, dependence,
insecurity, and jealousy. Abusers will often use fear and intimidation to the point where their victims will
do anything just to avoid further abuse. The statement that abuse occurs more often in lower
socioeconomic groups is incorrect.

25. Correct Answer : 4

Rationale: Tranylcypromine sulfate (Parnate) is a MAO inhibitor used to treat depression. A tyramine-
restricted diet is required while one is taking this medication, to avoid hypertensive crisis, a life-
threatening side effect of the medication. Foods to be avoided are meats prepared with tenderizer, smoked
or pickled fish, beef or chicken liver, and dry sausage (salami, pepperoni, bologna). In addition, figs,
bananas, aged cheese, yogurt and sour cream, beer, red wine, alcoholic beverages, soy sauce, yeast extract,
chocolate, caffeine, and aged, pickled, fermented or smoked foods need to be avoided. Many over-the-
counter medications also include tyramine and must be avoided as well.

26. Correct Answer : 3

Rationale: Amitriptyline hydrochloride is a tricyclic antidepressant often used to treat depression. The
client may experience some side effects, such as sedation, dry mouth, constipation, and blurred vision
(anticholinergic). However, these are transient and will diminish as time goes on. A more common adverse
effect is orthostatic change that can produce hypotension and tachycardia. This can be frightening to the
client and dangerous because it can result in dizziness and falling. The client must be instructed to move
slowly from a lying to a sitting or standing position to avoid injury if these changes are experienced. A
tyramine-free diet is initiated for a client on a monoamine oxidase inhibitor. Blood levels are required for
the client taking lithium.

27. Correct Answer : 3

Rationale: Lithium is the medication of choice to treat manic-depressive illness. Its exact mechanism of
action remains speculative; however, an equilibrium of sodium and potassium must be maintained at the
intracellular membrane to maintain therapeutic effects. Lithium competes with sodium in the cell. Many
over-the-counter medications contain sodium, and often prescription medications (diuretics) change the
sodium-potassium ratios of the cell, thus affecting lithium concentrations and the therapeutic levels of the
medication. Food restriction (tyramine-restricted diet) is associated with MAO Inhibitors. Antianxiety
agents (not lithium) are generally of an addictive nature. Lithium blood level tests are recommended but
are generally done every 3 to 4 months.

28. Correct Answer : 4

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Rationale: The side effects of lithium include fine hand tremors, polyuria, mild thirst, and mild nausea.
Diarrhea, vomiting, nausea, drowsiness, muscle weakness, and lack of coordination may be early signs of
toxicity. The medication is held and the physician notified so that the client can be further evaluated to
determine the presence of toxicity.

29. Correct Answer : 1

Rationale: A client who generalizes his or her fears to any place or situation earmarks agoraphobia.
Improvement is observed when the client is able to demonstrate appropriate coping behaviors for anxiety
reduction. Options 2 and 3 would not indicate improvement because the client is identifying the need to
take extra medication to cope. Option 4 is inappropriate because the client is demonstrating a "clock-
watching" with regard to the medication schedule.

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30. Correct Answer : 4

Rationale: In cognitive-behavioral therapy, the client with panic attacks will be treated with a
combination of cognitive restructuring, exposure therapy, and paradoxical intention. In paradoxical
intention, the client is instructed by the therapist to hyperventilate in order to cause a panic attack. When
this occurs, the nurse teaches the client to prevent the anxiety by a variety of coping mechanisms. This
assists the client to regain an internal locus of control or feeling of empowerment and to master the
anxiety-provoking issue, situation, or person. Option 1 describes in vivo therapy, which is a type of
exposure therapy. Option 2 describes systematic desensitization, another type of exposure therapy. Option
3 describes flooding, which is probably the most intensive therapy.

31. Correct Answer : 2

Rationale: Reflection, a technique that prompts the client by repeating the major theme in the client's
process, is a therapeutic communication technique. In option 1, the family therapist inappropriately uses a
sardonic response, which is nontherapeutic, because it gives advice. Option 3 is nontherapeutic because it
starts by agreeing and ends up bordering on being slightly threatening. Option 4 is not the most therapeutic
because it is premature in the therapy.

32. Correct Answer : 1

Rationale: Tardive dyskinesia is a severe reaction associated with long-term use of antipsychotic
medication. The clinical manifestations include abnormal movements (dyskinesia) and involuntary
movements of the mouth, tongue (flycatcher tongue), and face. In its more severe form, tardive dyskinesia
involves the fingers, arms, trunk, and respiratory muscles. When this occurs, the medication is
discontinued.

33. Correct Answer : 3

Rationale: When ECT is performed, the client may experience disorientation, attention difficulty, and
transient neurological abnormalities, which usually resolve within a few hours or days. The most
prominent adverse reaction is short-term anterograde and retrograde amnesia. Anterograde amnesia is
defined as the loss of the client's ability to retain newly learned information. This kind of amnesia usually
resolves within the first few weeks after ECT treatments. Retrograde amnesia is defined as difficulty
recalling information learned before ECT. This kind of amnesia may last longer. Option 1 describes short-
term anterograde amnesia. Options 2 and 4 describe short-term retrograde amnesia.

34. Correct Answer : 3

Rationale: It is strongly recommended that clients with anxiety disorder abstain from or limit their intake
of caffeine, chocolate, and alcohol. These products have the potential of increasing anxiety. Options 1 and
4 are unreasonable and are an unhealthy approach. It may not be realistic for a family member to take time
from work.

35. Correct Answer : 1

Rationale: Several conditions present risks in the client scheduled for ECT. These include clients with
recent myocardial infarction or cerebral vascular accident, and clients with cerebral vascular malformation
or an intracranial lesion.

36. Correct Answer : 1

Rationale: Clients with a long history of acting out and violent behavior and clients who have used drugs
need to demonstrate motivation to change the behavior, not just verbalization of the behavior. The most
therapeutic response by the nurse would be directed at assisting the client to look at the behaviors that
indicate the change. Option 1 is the only option that will provide this direction to the client.

37. Correct Answer : 4

Rationale: The most therapeutic communication technique is clarification, which attempts to put vague
ideas into words. It helps the client to view the explicit correlation between the client's feelings and

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actions. Asking why a client lost a job is not directly related to the client's feelings and concerns. Offering
to provide a homeless shelter or to commit the client to the hospital does not address the issue at hand and
places the client's concerns and feelings on hold.

38. Correct Answer : 4

Rationale: The most therapeutic response by the nurse is the one that makes the client aware of the
verbal statement and directs the client to the purpose of the session. The nurse should confront the client
verbally about the client's statement and refocus the client back to the issue of the session.

39. Correct Answer : 1

Rationale: Acute toxicity of MAO inhibitors is manifested by restlessness, anxiety, and insomnia.
Dizziness and hypertension can also occur in acute toxicity. Options 2, 3, and 4 are not signs of toxicity
related to MAO inhibitors.

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40. Correct Answer : 4

Rationale: A client who is depressed sees the negative side of everything. Telling the client that he or
she looks lovely today can be interpreted, as "I didn't look lovely last time we met." Neutral comments
such as that identified in option 4 will avoid negative interpretations. The client should not be told not to
worry, that he or she will feel better, or that everyone gets depressed once in a while because these are
inappropriate statements.

41. Correct Answer : 4

Rationale: When a client is experiencing psychomotor agitation it is best to provide activities that
involve the use of hands and gross motor movements. Such activities can include Ping-Pong, volleyball,
finger-painting, drawing, and working with clay. These activities provide an appropriate way for the client
to discharge motor tension. Simple card games and reading are sedentary activities. Playing checkers
requires concentration and more intensive use of thought processes.

42. Correct Answer : 1

Rationale: In caring for a client with depression and a diagnosis of Altered Nutrition: less than body
requirements, the nurse should remain with the client during the meal. The nurse should also assist the
client in selecting foods from the menu, since the client is more likely to eat the foods that he or she likes.
Offering small, high-calorie, high-protein snacks and high-calorie fluids throughout the day and evening
are appropriate interventions for the client to maintain nutrition.

43. Correct Answer : 1

Rationale: An inappropriate affect refers to an emotional response to a situation that is incongruent with
the tone of the situation. A flat affect is an immobile facial expression or blank look. A blunted affect is a
minimal emotional response, expresses the client's outward affect, and may not coincide with the client's
inner emotions. A bizarre affect such as grimacing, laughing, and mumbling to one's self is marked when
the client is unable to relate logically to the environment.

44. Correct Answer : 2

Rationale: A flat affect is an immobile facial expression or blank look. An inappropriate affect refers to
an emotional response to a situation that is incongruent with the tone of the situation. A blunted affect is a
minimal emotional response, expresses the client's outward affect, and may not coincide with the client's
inner emotions. A bizarre affect such as grimacing, laughing, and mumbling to one's self is marked when
the client is unable to relate logically to the environment.

45. Correct Answer : 2

Rationale: When caring for a client with paranoia the nurse must eliminate any physical contact and not
touch the client. The nurse should ask permission if touch is necessary, because touch may be interpreted
as a sexual or physical assault. The nurse should avoid a warm approach because warmth can be
frightening to a person who needs emotional distance. Simple and clear language should be used when
speaking to the client to prevent misinterpretation and to clarify the nurse's intent and action. The anger
that a paranoid client expresses is often displaced, and when staff becomes defensive, both client and staff
anger escalates.

46. Correct Answer : 4

Rationale: Enemas are not a component of the pretreatment care for a client scheduled for ECT. Options
1, 2, and 3 are a part of the pretreatment plan. Additionally, an informed consent is required, and the nurse
should teach the client and family what to expect with ECT and allow the client to discuss his or her
feelings about the procedure.

47. Correct Answer : 2

Rationale: An adverse reaction to carbamazepine is blood dyscrasias. If the client develops a fever, sore
throat, mouth ulcerations, unusual bleeding or bruising, or joint pain, the physician should be notified,

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because this could indicate a blood dyscrasia. Drowsiness, dizziness, nausea, and vomiting are frequent
side effects associated with the medication.

48. Correct Answer : 3

Rationale: Clients taking clozapine can develop hematological adverse reactions including
agranulocytosis and mild leukopenia. The WBC count should be assessed before initiating treatment and
should be monitored closely during the use of this medication. The client should also be monitored for
signs that indicate agranulocytosis, which may include sore throat, malaise, and fever. Options 1, 2, and 4
are incorrect.

49. Correct Answer : 3

Rationale: Antabuse is an adjunctive treatment for some clients with chronic alcoholism to assist in
maintaining enforced sobriety. Because clients must abstain from alcohol for at least 12 hours before the
initial dose, the most important assessment is that of when the last alcoholic intake was consumed. The
medication should be used cautiously in clients with diabetes mellitus, hypothyroidism, epilepsy, cerebral
damage, nephritis, and hepatic disease. It is contraindicated in clients with severe heart disease, psychosis,
or hypersensitivity to the medication.

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50. Correct Answer : 3

Rationale: Aricept is a cholinergic agent that is used in the treatment of mild to moderate dementia of
the Alzheimer's type. It increases the concentration of acetylcholine, which slows the progression of
Alzheimer's disease. The other options are incorrect.

51. Correct Answer : 2

Rationale: When assessing for suicide risk, the nurse must determine if the client has a suicide plan.
Clients who have a definitive plan pose a greater risk for suicide. Although options 1, 3, and 4 identify
questions that may provide information that will be helpful in planning care for the client, these questions
will not provide information about the risk of suicide.

52. Correct Answer : 3

Rationale: Somatization disorder is characterized by a long history of multiple physical problems with
no suitable organic cause. The clinical manifestations associated with schizophrenia, depression, and
obsessive-compulsive disorder are unrelated to somatic complaints.

53. Correct Answer : 3

Rationale: The client is instructed to shampoo and dry the hair the night before ECT treatment. In
addition, the client is instructed not to use hair sprays or creams prior to ECT to reduce the risk of burns.
While the client is on NPO status for 6 to 8 hours prior to treatment, 16 to 24 hours is not necessary. Some
hospitals place inpatient clients on NPO status at midnight before ECT in the morning. Some clients who
are on cardiovascular medication may be instructed to take their medicine with sips of water several hours
before ECT Option 2 is incorrect, as is option 4.

54. Correct Answer : 3

Rationale: Agoraphobia is a fear of leaving the house and experiencing panic attacks when doing so.
Option 1 describes an obsessive-compulsive behavior. Option 3 describes a social phobia. Option 4
describes claustrophobia.

55. Correct Answer : 3

Rationale: Constipation is a common elimination problem with clients in a manic phase of bipolar
disorder. Constipation may occur as the result of a combination of factors, including taking antipsychotic
medications; suppressing the urge to defecate; and a decreased fluid intake as the result of the manic
activity level. The symptoms listed in the question, "dehydration," "unkempt," "abdominal fullness and
discomfort," and "antipsychotic medications," in combination, are indicators of constipation. A high-fiber
diet and increased fluids can reduce constipation.

56. Correct Answer : 4

Rationale: In this situation, the nurse must override the duty to observe confidentiality and notify the
client's physician about the client's suicidal ideation. Option 1 is incorrect because the nurse has a moral
obligation to protect the client. Option 2 is incorrect because the client is homebound and the client must
be seen in the home. Option 3 is incorrect because the nurse has a moral obligation to intervene when a
client tells the nurse of his or her ideas or plans to harm himself or herself or others.

57. Correct Answer : 1

Rationale: Clients often forget to take their medications as scheduled, and this is the most prominent
problem. Options 2, 3, and 4 may occur, but they are not the most prominent problem, can be addressed,
and often are controlled.

58. Correct Answer : 1

Rationale: Eating binges and purging are the characteristics that are seen in bulimia. Eating only
certain types of foods may reflect a preference, but does not indicate bulimia. Bulimic persons usually do
not refuse to eat; they binge and purge. Hoarding of food may indicate another problem.

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59. Correct Answer : 2

Rationale: Sharing observations with the client may help him to recognize and acknowledge feelings.
Allowing the client to pace may allow him to become "out of control." Moving to a quiet room or changing
the subject will not help the client to recognize his behaviors and feelings.

60. Correct Answer : 2

Rationale: The major clinical manifestation associated with PTSD are client experiences of flashbacks.
Flashbacks are not specifically associated with agoraphobia, anxiety, or schizophrenia.

61. Correct Answer : 4

Rationale: It is important to make a confused client feel safe. Stabilizing psychiatric needs is a long-
term goal. Orientation and explaining the unit rules are part of any admission process.

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62. Correct Answer : 3

Rationale: Option 3 is the only option that addresses the client's feelings and concerns. Options 1 and 2
provide false reassurance and place the client's feelings on hold. Option 4 is a nontherapeutic
communication technique and will increase the client's anxiety.Q

63. Correct Answer : 1

Rationale: Following three treatments of electroconvulsive therapy, the client should start to
demonstrate improvement in 1 week. Options 2, 3, and 4 are incorrect.

64. Correct Answer : 2

Rationale: A depressed client may eat small amounts of food rather than large amounts that may be
overwhelming to them. If the client becomes overwhelmed, she may respond by withdrawing further.
Providing snacks and meals when the client requests them will not ensure adequate nutritional intake.
Forcing foods and fluids and telling the client that social activities will be restricted will cause further
withdrawal in the client. Option 4 is also a demeaning action.

65. Correct Answer : 3

Rationale: Antabuse is the medication of choice for alcoholism, and it aids in the maintenance of
sobriety. Librium is an antianxiety and benzodiazepine used in the management of acute alcohol
withdrawal symptoms. Catapres is an antihypertensive medication. Pyridoxine hydrochloride is used in the
treatment of pyridoxine deficiency.

66. Correct Answer : 1

Rationale: Option 1 encourages the client to socialize and indicates that it is not necessary to sing.
Option 2 uses the word "why"; the use of this word should be avoided. Options 3 and 4 imply a demand
and do not address the client's concern. Option 1 is the only option that addresses the client's concern.

67. Correct Answer : 3

Rationale: The best indicator that the behavior is controlled is the client exhibiting no signs of
aggression after partial release of restraints. Options 1, 2, and 4 do not ensure that the client has controlled
the behavior.

68. Correct Answer : 2

Rationale: The behaviors identified in the question indicate improvement in the client's condition.
There is no information in the question that indicates that the client is being manipulative. Acting out is
attention-seeking behavior. All clients have a desire to be accepted.

69. Correct Answer : 3

Rationale: ECT as a form of treatment is considered when medication therapy has failed, when the
client is at high risk for suicide, or when depression is judged to be overwhelmingly severe. Treatments are
administered three times a week, with an average series involving 8 to 12 treatments over a duration of 2 to
4 weeks. The most common side effect is amnesia of events occurring near the period of the treatment.
Memory deficits may occur and tend to resolve with time.

70. Correct Answer : 4

Rationale: Biofeedback, progressive muscle relaxation, meditation, and guided imagery are techniques
that the nurse can teach the client to reduce the physical impact of stress on the body and promote a feeling
of self-control. Biofeedback uses electronic equipment, whereas the other techniques require no equipment
after they are learned. Confrontation is not a stress management technique; it is a communication
technique.

71. Correct Answer : 4

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Rationale: Adolescent pregnancy outside of marriage can arise from female low self-esteem, fears of
inadequacy, and desperation to escape an abusive and dysfunctional family. The most therapeutic
communication technique is the one that uses restatement and repeats the main thought that the client
expressed. This assures the client that the nurse is listening and is attempting to validate what she has said.
Options 1, 2, and 3 are nontherapeutic. Option 1 reflects knowledge deficit on the nurse's part. Option 2 is
insensitive and makes assumptions. Option 3 makes connections that are assumed and imply judgmental
bias.

72. Correct Answer : 3

Rationale: Milieu therapy, or "therapeutic community," has as its locus a living, learning, or working
environment. Such therapy may be based on any number of therapeutic modalities, from structured
behavioral therapy to spontaneous, humanistically oriented approaches. Although milieu may include
behavioral approaches, its primary focus is described in option 3.

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73. Correct Answer : 2

Rationale: The exact cause of depression is not known, but it is believed to be related to a biochemical
disruption of neurotransmitters in the brain. Diet, exercise, and medication are recognized treatments of the
disease process. Options 1, 3, and 4 offer no insight into the disease process. In addition, option 1 reflects
possible blaming or personal failure, and option 3 reflects an unwillingness to reach out to others.

74. Correct Answer : 3

Rationale: Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy,
decreased need for sleep, and impaired ability to concentrate or stay with a single train of thought. It is a
period when the mood is predominantly elevated, expansive, or irritable. All of the options reflect a client's
possible symptomatology. Option 3, however, clearly presents a problem that compromises one's
physiological integrity and needs to be addressed immediately.

75. Correct Answer : 2

Rationale: A person who is experiencing mania is overactive, full of energy, lacks concentration, and
has poor impulse control. The client needs an activity that will allow him or her to use excess energy but to
not endanger others during the process. Options 1, 3, and 4 are relatively sedate activities that require
concentration, which is a quality that is lacking during the manic state. Such activities may lead to
increased frustration and anxiety for the client. Tetherball is an exercise that uses the large muscle groups
of the body, and it is a great way to expend the increased energy that this client is experiencing.

76. Correct Answer : 3

Rationale: It is most therapeutic for the nurse to empathize with the client's experience. Disagreeing
with delusions may make the client more defensive, and the client may cling to the delusions even more.
Encouraging discussion about the delusion is inappropriate.

77. Correct Answer : 1

Rationale: If a client with severe anxiety is left alone, he or she may feel abandoned and become
overwhelmed. Placing the client in a quiet room is also important, but the nurse must stay with the client. It
is not possible to teach the client deep-breathing or relaxation exercises until the anxiety decreases.
Encouraging the client to discuss concerns and feelings would not take place until the anxiety has
decreased.

78. Correct Answer : 1

Rationale: It is important to provide a consistent daily routine and a low-stimulation environment when
the client is disorientated. Noise, including radio and television, may add to the confusion and
disorientation. Moving the client next to the nurses' station is not the initial action.

79. Correct Answer : 4

Rationale: In option 4, the nurse encourages the client and the family to verbalize fears and concerns.
Options 1, 2, and 3 avoid dealing with concerns and are blocks to communication.

80. Correct Answer : 4

Rationale: The clinical picture of dementia varies from the development of mild cognitive defects to
severe, life-threatening alterations in neurological functioning. It is not unusual for the client to employ
confabulation or the fabrication of events or experiences to fill in memory gaps. Often a lack of inhibition
on the part of the client may constitute the first indication of anything being "wrong" to the client's
significant others (the client may undress in front of people or demonstrate slovenly table manners,
whereas in the past the client was very well-mannered). As the dementia progresses, the client will have
episodes of wandering or sundowning.

81. Correct Answer : 2

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Rationale: There may be an increased risk for impulsive and/or aggressive behavior if a client is
receiving command hallucinations to harm self or others. The client should be asked about his or her
intentions to hurt. Talking about auditory hallucinations can interfere with the subvocal muscular activity
associated with a hallucination. Options 1, 3, and 4 will aid in wellness, but they are not specific
interventions for hallucinations.

82. Correct Answer : 2

Rationale: All clients, regardless of age, need to be encouraged to perform at the highest level of
independence possible. This contributes to the client's sense of control and well-being. Option 1 is
incorrect, because one does not know what the "self-care deficit" entails. To assume that the client requires
long-term care on such little data would be erroneous. Options 3 and 4 are absolute statements.

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83. Correct Answer : 1

Rationale: Safety of the client and other clients is the priority. Option 1 is the only option that
addresses the client and other clients' safety needs. Option 2 addresses only the client's needs. Option 3
addresses only other clients' needs. Option 4 is not client-centered.

84. Correct Answer : 3

Rationale: Clients who are withdrawn may be immobile and mute and require consistent, repeated
approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions
include the establishment of interpersonal contact. The nurse facilitates communication with the client by
sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to
respond.

85. Correct Answer : 1

Rationale: "Altered thought process secondary to paranoia" is the client's problem, and the plan of care
must address this problem. The client is experiencing paranoia and is distrustful and suspicious of others.
The members of the health care team need to establish rapport and trust with the client, so laughing or
whispering in front of the client would be counterproductive. Options 2, 3, and 4 ask the client to trust on a
multitude of levels; these options are actions that are too intrusive for a client who is paranoid.

86. Correct Answer : 4

Rationale: A client with depression often has a depressed mood and is often withdrawn. Also, the
person experiences difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of
worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a
stimulating yet structured environment. Options 1, 2, and 3 are too restrictive and offer little or no structure
or stimulation.

87. Correct Answer : 2

Rationale: Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety
or avoid specific stimuli. Counselors will not be available for all anxiety-producing situations, and this
option does not encourage the development of internal strengths. Ignoring feelings will not resolve anxiety.
It is impossible to eliminate all anxiety from life.

88. Correct Answer : 2

Rationale: Agoraphobia is a fear of open spaces and the fear of being trapped in a situation from which
there may not be an escape. Agoraphobia includes the possibility of experiencing a sense of helplessness or
embarrassment if an attack occurs. Avoidance of such situations usually results in reduction of social and
professional interactions. Social phobia focuses more on specific situations such as the fear of speaking,
performing, or eating in public. Claustrophobia is a fear of closed places. Clients with hypochondriacal
symptoms focus their anxiety on physical complaints and are preoccupied with their health.

89. Correct Answer : 3

Rationale: Aspiration is safeguarded against by keeping the client NPO for 6 to 8 hours before ECT,
removing dentures, and administering preprocedure medications as prescribed. Although options 1 and 2
could also be appropriate nursing diagnoses, they are not the priority. There is no reason to assume that
option 4 is even a consideration.

90. Correct Answer : 2

Rationale: A conversion disorder is the alteration or loss of a physical function that cannot be explained
by any known pathophysiological mechanism. It is thought to be an expression of a psychological need or
conflict. In this situation, the client witnessed an accident that was so psychologically painful that the
client became blind. A dissociative disorder is a disturbance or alteration in the normally integrative
functions of identity, memory, or consciousness. Psychosis is a state in which a person's mental capacity to
recognize reality, communicate, and relate to others is impaired, thereby interfering with the person's

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capacity to deal with life demands. Repression is a coping mechanism in which unacceptable feelings are
kept out of awareness.

91. Correct Answer : 1

Rationale: The client is at risk for injury to self and others and therefore should be escorted out of the
day room. Antipsychotic medications are useful to manage the manic client. Hyperactive and agitated
behavior usually responds to haloperidol (Haldol). Option 2 may increase the agitation that already exists
in this client. Orientation will not halt the behavior. Telling the client that the behavior is not appropriate
has already been attempted by the nurse.

92. Correct Answer : 3

Rationale: Clients with anorexia nervosa are frequently preoccupied with rigorous exercise and push
themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate
exercise and place limits on rigorous activities. Options 1, 2, and 4 are inappropriate nursing actions.

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93. Correct Answer : 4

Rationale: Clients with anorexia nervosa have the desire to please others. Their need to be correct or
perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals
help the clients manage their anxiety.

94. Correct Answer : 1

Rationale: The symptoms associated with DTs typically are anxiety, insomnia, anorexia, hypertension,
disorientation, visual or tactile hallucinations, changes in level of consciousness, agitation, fever, and
delusions.

95. Correct Answer : 2

Rationale: The most helpful response is one that encourages the client to problem-solve. Giving advice
implies that the nurse knows what is best and can also foster dependency. The nurse should not agree with
the client, nor should the nurse request that the client provide explanations.

96. Correct Answer : 3

Rationale: Whenever the nurse employs an assessment for a client who is dependent on drugs, it is
best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect,
because it is judgmental, off-focus, and reflects the nurse's bias. Option 2 is incorrect, because it is
judgmental, insensitive, and aggressive, all of which are nontherapeutic. Option 4 is incorrect, because it
indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention.

97. Correct Answer : 2

Rationale: A client receiving diagnostic tests is an acceptable roommate. The client with anorexia is
most likely experiencing hematological complications such as leukopenia. Having a roommate with
pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia
nervosa should not be put into a situation in which he or she is able to focus on the nutritional needs of
others or being managed by others, because this may contribute to sublimation and suppression of the
client's own hunger.

98. Correct Answer : 2

Rationale: Al-Anon support groups are a protected, supportive opportunity for spouses and significant
others to learn what to expect and to obtain excellent pointers about successful behavioral changes. Option
2 is the most healthy response, because it exemplifies an understanding that the alcoholic partner is
responsible for his behavior and cannot be allowed to blame family members for loss of control. With
regard to option 1, the nonalcoholic partner should not feel responsible when the spouse loses control.
Option 3 indicates that the wife remains codependent. Option 4 indicates that the group is being seen as an
escape, not a place to work on issues.

99. Correct Answer : 3

Rationale: In the defense mechanism of denial, the person denies reality. Option 1 identifies denial. In
option 2, the client is relying heavily on others, and the client's focus of control is external. In option 4, the
client is concrete and procedure-oriented; again, the client maintains that "nothing will go wrong" if the
client follows all directions. In option 3, the client is expressing real concern and ambivalence about
discharge from the hospital. The client also demonstrates reality in the statement.

100. Correct Answer : 4

Rationale: A nurse can be charged with false imprisonment if a client is made to wrongfully believe
that he or she cannot leave the hospital. Most health care facilities have documents that the client is asked
to sign that relate to the client's responsibilities when they leave against medical advice (AMA). The client
should be asked to sign this document before leaving. The nurse should request that the client wait to speak
to the physician before leaving, but if the client refuses to do so, the nurse cannot hold the client against his

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or her will. Restraining the client and calling security to block exits constitutes false imprisonment. Any
client has a right to health care and cannot be told otherwise.

101. Correct Answer : 4

Rationale: Clients with bulimia nervosa may not initially appear to be physically or emotionally ill.
They are often at or slightly below ideal body weight. On further inspection, the client demonstrates dental
decay and loss of tooth enamel, which is a result of the client inducing vomiting. Electrolyte imbalances
are present.

102. Correct Answer : 3

Rationale: A situational crisis arises from external rather than internal sources. External situations that
could precipitate crisis include the loss of or change of a job; the death of a loved one; an abortion; a
change in financial status; divorce; the addition of new family members; pregnancy; and severe illness.
Options 1, 2, and 4 identify adventitious crisis, which is not a part of every day life and is unplanned and
accidental.

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103. Correct Answer : 1

Rationale: A nurse's initial task when assessing a client in crisis is to assess the individual or family
and the problem. The more clearly the problem can be defined, the better the chance that a solution can be
found. Option 1 will assist in determining data related to the precipitating event that led to the crisis.
Options 2 and 4 assess situational supports. Option 3 assesses personal coping skills.

104. Correct Answer : 4

Rationale: Although each crisis response can be described in similar terms as far as presenting
symptoms are concerned, what constitutes a crisis for one person may not constitute a crisis for another
person, because each person is a unique individual. Being in the crisis state does not mean that the client is
suffering from an emotional or mental illness.

105. Correct Answer : 1

Rationale: The best option is to ask the client what is causing the agitation; this will help the client to
become aware of the behavior, and it may assist the nurse in planning appropriate interventions for the
client. Option 2 is demanding behavior that could cause increased agitation in the client. Options 3 and 4
are threats to the client and are inappropriate.

106. Correct Answer : 4

Rationale: During the escalation period, the client's behavior is moving toward loss of control. Nursing
actions include taking control; maintaining a safe distance; acknowledging behavior; moving the client to a
quiet area; and medicating the client, if appropriate. It is not appropriate during this period to initiate
confinement measures; confinement measures are most appropriate during the crisis period.

107. Correct Answer : 4

Rationale: A depressed, suicidal client often gives away that which is of value as a way of saying
good-bye and wanting to be remembered. Options 1, 2, and 3 deal with anger and acting out behaviors,
which are often typical of any adolescent.

108. Correct Answer : 1

Rationale: Hanging is a serious suicide attempt. The plan of care must reflect action that will promote
the client's safety. Constant observation status (one-to-one) with a staff member who is never less than an
arm's length away is the best selection. Seclusion should not be the initial intervention, and the least
restrictive measure should be used. Placing the client in a hospital gown and requesting that a peer remain
with the client will not ensure a safe environment.

109. Correct Answer : 1

Rationale: The initial nursing action is to assess and treat the self-inflicted injuries. Injuries from
lacerated wrists can lead to a life-threatening situation. Other interventions may follow after the client has
been treated medically.

110. Correct Answer : 4

Rationale: A suicidal client may have numerous diagnoses that encompass inadequate coping skills,
anxiety, and strained interpersonal relationships. The question, however, directly and clearly designates
that the problem that needs to be dealt with is the "high risk for violence, self-directed" and that the client
has both the ideation and a plan. The expected outcome is that the client no longer has suicidal ideations
and has identified options to deal with stress. Options 1, 2, and 3 are not directly related to the nursing
diagnosis as stated in the question.

111. Correct Answer : 4

Rationale: In a crisis, the nurse must take an authoritative, active role to promote the client's safety. A
bottle of sleeping pills in front of a client who verbalizes that he wants to kill himself is a crisis. The
client's safety is of prime concern. Keeping the client on the phone and getting help to the client is the best

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intervention. Insisting that the client provide his name may anger the client, and he might hang up. Option
2 lacks the authoritative action stance of securing the client's safety. Using therapeutic communication
techniques is important, but overuse of reflection may sound uncaring or superficial and is lacking
direction and solutions to the immediate problem of the client's safety.

112. Correct Answer : 1

Rationale: The question is focused on the nursing diagnosis of dysfunctional grieving. The only option
that deals with grief is option 1. Options 2, 3, and 4 are unrelated to this nursing diagnosis.

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113. Correct Answer : 1

Rationale: The symptoms of major depression includes depressed mood, loss of interest or pleasure,
changes in appetite and sleep patterns, psychomotor agitation or retardation, fatigue, feelings of
worthlessness/guilt, diminished ability to think or concentrate, and recurrent thoughts of death. Often the
clients do not have the energy or interest to complete activities of daily living. Option 3 may lead to
increased feelings of worthlessness as the client fails to meet expectations. Option 4 will increase the
client's feelings of poor self-esteem and unworthiness.

114. Correct Answer : 1

Rationale: The client in seclusion must be assessed at regular intervals (usually every 15 to 30
minutes) for physical needs, safety, and comfort. Option 2 indicates a physical need that could be met with
a urinal or a bedpan, if necessary; it does not indicate that the client has calmed down enough to leave the
seclusion room. Option 3 could be an attempt to manipulate the nurse; there is no indication that the client
will control him- or herself when alone in their room. Option 4 indicates the need for supportive
communication or possibly a prn medication; it does not necessitate discontinuing seclusion.

115. Correct Answer : 2

Rationale: Crisis times may occur between appointments. Contracts facilitate the client feeling a
responsibility for keeping a promise; this gives the client control. Option 3 is unrealistic. Providing phone
numbers will not assure available and immediate crisis intervention.

116. Correct Answer : 4

Rationale: A client who is moderately depressed and has only been in the hospital for 2 days is very
unlikely to have such a dramatic cure. When a mood suddenly lifts, it is very likely that the client may
have made the decision to harm him-or herself. Suicide precautions are necessary to keep the client safe.

117. Correct Answer : 3

Rationale: One-to-one suicide precautions are required for the client who has attempted suicide.
Options 1 and 2 may be appropriate, but they are not appropriate at the present time, considering the
situation. Option 4 may also be an appropriate nursing intervention, but the priority is identified in option
3. The best intervention is constant supervision so that the nurse may intervene as needed if the client
attempts to cause harm to self.

118. Correct Answer : 4

Rationale: Whenever the abused client remains in the abusive environment, priority must be placed on
ascertaining whether the person is in any immediate danger. If so, emergency action must be taken to
remove the client from the abusing situation. Options 1, 2, and 3 may be appropriate interventions, but they
are not the priority.

119. Correct Answer : 2

Rationale: Tertiary prevention of family violence includes assisting the victim after the abuse has
already occurred. The nurse should provide the client with information about where to obtain help; this
includes a specific plan for removing the client from the abuser, information about escaping, hot line
numbers, and the location of shelters. An abused person is usually reluctant to call the police. Teaching the
victim to fight back is not the appropriate action for the victim who is dealing with a violent person.

120. Correct Answer : 2

Rationale: Option 2 allows the client to express her ideas and feelings more fully and portrays a
nonhurried, nonjudgmental, supportive attitude. Clients need to be reassured that their feelings are normal
and that they may freely express their concerns in a safe, caring environment. Option 1 places the problem
solving totally on the client. Option 3 places the client's feelings on hold. Option 4 immediately blocks
communication.

121. Correct Answer : 1

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Rationale: Short-term goals will include the beginning stages of dealing with the rape trauma. Clients
will be expected initially to keep appointments, participate in care, begin to explore feelings, and begin to
heal any physical wounds that were inflicted at the time of the rape.

122. Correct Answer : 4

Rationale: Options 1, 2, and 3 identify a positive movement toward increased self-esteem and problem
solving. Option 4 places undue pressure on the client by implying that the client was negligent and
contributed to the loss.

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123. Correct Answer : 3

Rationale: Nursing interventions for the Alzheimer client who is angry, frustrated, or hostile include
decreasing environmental stimuli, approaching the client calmly and with assurance, not demanding
anything from the client, and distracting the client. It is important that the nurse reach out, touch, hold a
hand, put an arm around the waist, or in some way maintain physical contact. Playing a radio may increase
stimuli and turning the lights out may produce more agitation. The client with Alzheimer's disease would
not be a candidate for group work if he or she is agitated.

124. Correct Answer : 1

Rationale: Systematic desensitization is a form of therapy used when the client is introduced to short
periods of exposure to the phobic object while in a relaxed state. Gradually, exposure is increased until the
anxiety about or fear of the object or situation has ceased. Options 2, 3, and 4 are incorrect.

125. Correct Answer : 4

Rationale: The sponsor of a self-help group is an experienced member of the group. A nurse or
psychiatrist may be asked by the group to serve as a resource but would not be the leader of the group.
Options 1, 2, and 3 are characteristics of a self-help group.

126. Correct Answer : 4

Rationale: The first step in the 12-step program is to admit that a problem exists. Options 1 and 2 are
unrealistic as a first step in the process to recovery. Although option 3 may be a strategy, it is not the first
step.

127. Correct Answer : 1

Rationale: If a client is monopolizing the group, it is important that the nurse be direct and decisive.
The best action is to suggest that the client stop talking and try listening to others. Although option 3 may
be a direct response, option 1 is the most therapeutic direct statement. Options 2 and 4 are inappropriate.

128. Correct Answer : 1

Rationale: The ideal number of clients in a psychotherapy group ranges from 7 to 10. Having more
than 10 members is not recommended, because the group will subdivide, which is counterproductive. Too
large a group can also create more opportunities for acting out, as opposed to working through issues.

129. Correct Answer : 1

Rationale: In the forming or initial stage, the members are identifying tasks and boundaries. Storming
involves responding emotionally to tasks. In the norming stage, members express intimate personal
opinions and feelings around personal tasks. In the performing stage, members direct group energy toward
the completion of tasks.

130. Correct Answer : 2

Rationale: Solitary activities that require a short attention span with mild physical exertion are the most
appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with
staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension.
Competitive games should be avoided, because they can stimulate aggression and increase psychomotor
activity.

131. Correct Answer : 4

Rationale: Change in appetite is one of the major symptoms of depression. Other symptoms include a
depressed mood; increased fatigue; feelings of worthlessness; diminished ability to think or indecisiveness;
and psychomotor agitation or retardation. Option 1 is incorrect, because the client is experiencing poor
concentration; hence, even if the client does understand the rationale, he or she still may not be able to
complete tasks. Weighing the client does not address a way to increase nutritional intake. Reporting to the

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psychiatrist and the nutritionist is to some degree correct, but that option lacks the method as to how one
might Increase the client's food intake.

132. Correct Answer : 1

Rationale: This child's behavior is a warning signal of distress. Option 1 is the only option that
specifically addresses abuse. In option 2, the nurse is insensitive, sarcastic, and intrusive. In option 3, the
nurse is assessing the client's destructive behaviors, not the possible sexual abuse history. Option 4,
although trying to assess the client's abuse-related symptoms, uses indirect means rather than
straightforward expressions of the nurse's concern.

133. Correct Answer : 2

Rationale: Option 2 addresses the issue of the client's statement. Options 1 and 4 are statements that
identify the process of agreeing with the client. Option 3 is not directly related to the issue of the client's
statement.

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134. Correct Answer : 1

Rationale: CCU psychosis occurs in some clients in critical care settings. It fluctuates over the course
of a day and usually is directly caused by sensory deprivation and/or medication-related or underlying
medical conditions. There is no data in the question to indicate that alcohol is a concern. Options 3 and 4
both address dementia, and there is no data in the question to indicate that dementia exists.

135. Correct Answer : 3

Rationale: The client is displacing anger by yelling and throwing down the chair. The nurse first sets
limits on the client's behavior. The nurse reinforces group rules, physical safety, and a sense of control.
Options 1 and 2 are premature at this point. Exploration may occur later in the group process. Option 4
may be the second action, but only if the client presents with escalating behavior.

136. Correct Answer : 2

Rationale: Rationalization is substitution of acceptable reasons for actual reasons for behavior. In option
2, the client is rationalizing and is minimizing the response to loss. Options 1, 3, and 4 all indicate that the
client is reviewing and evaluating certain valued perceptions of the treatment process prior to discharge.

137. Correct Answer : 4

Rationale: The most therapeutic communication technique is one that uses reflection and facilitates the
client's feelings. In addition, a supportive communication that encourages and supports other clients to
connect or relate by responding to the client's statement is the most therapeutic response by the nurse.

138. Correct Answer : 2

Rationale: When the illness (Alzheimer's disease) affects the temporal-parietal-occipital association
cortex, the client may experience the inability to identify well-known objects and people. This is called
agnosia. The client may also experience difficulty finding the right word to use (aphasia) and an inability
to perform familiar skilled activities (apraxia). Ataxia describes altered motor function.

139. Correct Answer : 3

Rationale: The schizophrenic client is making a paranoid statement. It is important that the nurse
provide the client with a supportive and a protective intervention. Option 1 is not therapeutic because the
nurse feeds into the client's psychosis by asking where the fantasy person is. Option 2 is not therapeutic
because the nurse is sarcastic and belittling to the client. Option 4 is not therapeutic because although the
nurse begins by presenting reality, the nurse then is demeaning to the client.

140. Correct Answer : 1

Rationale: The most therapeutic response is one that sets limits on the client's interruptive behavior
and assesses the client's ability to control his behavior. In option 2, the nurse uses restating and feeds into
the client's delusional system, which is not therapeutic and belittles the client's mental status. In option 3,
the nurse uses a playful and mothering type of social response, which may escalate the client. In option 4,
the nurse chastises the client for behavior that is not within the client's control.

141. Correct Answer : 4

Rationale: Loose associations are speech patterns in which there is a lack of a logical relationship
between thoughts and ideas, causing speech and thought to seem inexact, vague, unfocused, and diffuse.
Flight of ideas is overproductive speech characterized by the client's quickly switching from one subject to
another with only a sense of fragmented ideas. Incoherence is characterized by speech that cannot be
understood. Tangential speech is an inappropriate response to a statement in which the content of the
statement is disregarded. Clanging is a form of rhyming that is not comprehensible, but the client seems to
be caught up in the sound of the words.

142. Correct Answer : 3

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Rationale: Noncompliance with antipsychotic medication is one of the chief reasons that clients with
schizophrenia have relapses. The nurse teaches the schizophrenic client to identify the causes of relapse. In
option 1, the nurse is employing restating which, while therapeutic, is not useful to this client and to this
client's situation. In option 2, the nurse is again using restating. In option 4, the nurse is using an illogical,
judgmental, and biased response, which is not therapeutic.

143. Correct Answer : 3

Rationale: The most appropriate initial nursing action is to sit and talk to the client if the client is
expressing anxiety. Antianxiety medication may be necessary, but this would not be the initial most
appropriate nursing action. A nursing assistant may not be able to alleviate the client's anxiety. Option 2 is
an inappropriate action and places the client's feelings on hold.

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144. Correct Answer : 3

Rationale: Multiple personality disorder or dissociative identity disorder is considered to be a
"dissociative disorder" rather than an anxiety disorder. Anxiety is a characteristic of panic disorder, OCD,
and PTSD.

145. Correct Answer : 4

Rationale: Rigid and inflexible behaviors are characteristics of the client with OCD. Clients with this
disorder are not usually hostile unless they are prevented from engaging in the obsession or compulsion,
since this behavior is what decreases the anxiety. Options 1 „ 2, and 3 are incorrect and are not
characteristics of OCD.

146. Correct Answer : 4

Rationale: A repetitive behavior that interferes with activities of daily living and functioning is
indicative of OCD. This repetitive behavior is not associated with generalized anxiety disorder, phobias, or
PTSD.

147. Correct Answer : 2

Rationale: A compulsion is a repetitive act, and an obsession is a repetitive thought. The client with a
phobia is likely to experience repetitive fears. Illusions are characteristic of schizophrenia.

148. Correct Answer : 3

Rationale: In OCD, the rituals performed by the client are an unconscious response that helps to divert
and control the unpleasant thought or feeling to prevent acting on it. Options 1, 2, and 4 are incorrect.

149. Correct Answer : 2

Rationale: The initial nursing action would be to assess for any physiological causes of the paralysis.
Although a component of the plan of care would be to encourage the client to discuss feelings, this would
not be the initial nursing action. It is not appropriate to encourage the client to use the arm without ruling
out a physiological cause of the paralysis. Although the client may be referred to a psychiatrist, this also is
not the initial action.

150. Correct Answer : 4

Rationale: The initial nursing action is to establish a trusting relationship with the client. Demanding
anything from the client should never occur. The remaining options are appropriate components of the plan
of care, but they are not the priority. A trusting nurse client relationship needs to be established first.

151. Correct Answer : 2

Rationale: The priority would include developing individualized goals and objectives in the plan of care.
Goals and objectives are mutual working tools between the client and the nurse. Although the medical
diagnosis of the client is considered in planning care, it is not specifically a component of a nursing care
plan. Attendance at group therapy sessions and promoting self-care measures may be a component of the
plan of care but these interventions would follow after developing the goals and objectives.

152. Correct Answer : 4

Rationale: Emotional turmoil expressed in physical signs is a major symptom of somatization disorder.
Options 1, 2, and 3 are not associated with these assessment findings.

153. Correct Answer : 1

Rationale: The client undergoing LP is positioned lying on the side, with the legs pulled up to the
abdomen, and with the head bent down onto the chest. This position helps to open the spaces between the
vertebrae.

154. Correct Answer : 4

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Rationale: Spinal immobilization is necessary after spinal cord injury to prevent further damage and
insult to the spinal cord. Whenever possible, the client is placed on a Stryker frame, which allows the nurse
to turn the client to prevent complications of immobility, while maintaining alignment of the spine. If a
Stryker frame is not available, a firm mattress with a bedboard under it should be used.

155. Correct Answer : 2

Rationale: Typically, seizure assessment includes the time the seizure began, part(s) of the body affected,
the type of movements and progression of the seizure, changes in pupil size, eye deviation or nystagmus,
client condition during the seizure, and postictal status.

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156. Correct Answer : 3

Rationale: Typical anticonvulsant medication instructions include taking the dose daily to keep the
blood level of the drug constant and having a serum drug level drawn before taking the morning dose. The
client is taught not to abruptly stop the medication; avoid alcohol; check with the physician before taking
over-the-counter medications; avoid activities where alertness and coordination are required until
medication effects are known; provide good oral hygiene and obtain regular dental care. The client should
also wear a Medic-Alert bracelet.

157. Correct Answer : 3

Rationale: The client with Guillain-Barre syndrome is at risk for respiratory failure because of ascending
paralysis. An intubation tray should be available for use. Another complication of this syndrome is cardiac
dysrhythmia, which necessitates the use of ECG monitoring. Because the client is immobilized, the nurse
should routinely assess for deep vein thrombosis and pulmonary embolism.

158. Correct Answer : 3

Rationale: In the termination phase, the relationship comes to a close. Ending treatment can sometimes
be traumatic for clients who have come to value the relationship and the help. Since loss is an issue, any
unresolved feelings related to loss may resurface during this phase. Options 1, 2, and 4 are incorrect.

159. Correct Answer : 3

Rationale: Responding to the feelings expressed by a client is an effective therapeutic communication
technique. The correct option is an example of the use of restating. Options 1, 2, and 4 block
communication because they minimize the client's experience and do not facilitate exploration of the
client's expressed feelings.

160. Correct Answer : 4

Rationale: The most therapeutic nursing communication technique is restatement. Although it is a
technique that has a prompting component to it, it repeats the client's major theme, which assists the nurse
to obtain a more specific perception of the problem from the client. Options 1, 2, and 3 are not therapeutic
responses.

161. Correct Answer : 3

Rationale: Option 3 is the only option that identifies a therapeutic response. In option 1, the nurse's
feelings are the focus. This response clearly ignores the fact that the issue is about the client and the client's
discomfort, not about the nurse. In option 2, the nurse becomes pompous and a bit angry and supercilious,
which is not therapeutic. In option 4, the nurse begins correctly with an empathic stance but then becomes
demanding.

162. Correct Answer : 4

Rationale: Native Americans view touch very differently from other Americans. The most therapeutic
response is the one that reflects the client's feelings and empowers the client by offering self control over
one's own care. In option 1, the nurse uses avoidance and information giving. Option 2 is an aggressive and
nontherapeutic communication technique. Option 3 labels the client's behavior and is likely to provoke
anger.

163. Correct Answer : 1

Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss their
problem. Options 2 and 3 are not helpful to the client because they do not encourage the client to express
feelings. The nurse should not offer opinions and should encourage the client to identify the reasons for the
behavior. Option 4 is not a client-centered intervention.

164. Correct Answer : 4

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One candle wipes out darkness…….

Rationale: The client must first deal with feelings and negative responses before being able to work
through the meaning of the crisis. Option 4 pertains directly to the client's feelings. Options 1, 2, and 3 do
not directly address the client's feelings.

165. Correct Answer : 1

Rationale: Denial is an adaptive and protective reaction and may be a response by a victim of sexual
abuse. Projection is transferring one's internal feelings, thoughts, and unacceptable ideas and traits to
someone else. Rationalization is justifying the unacceptable attributes about oneself. Intellectualization is
the excessive use of abstract thinking or generalizations to decrease painful thinking.

166. Correct Answer : 3

Rationale: The client's thoughts are extremely important when verbalized. A client's report of suicidal
thoughts is of highest priority. Options 1, 2, and 4 will all affect the treatment of the client but are not of
greatest importance at this time.

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167. Correct Answer : 4

Rationale: Option 4 helps the client to focus on the emotion underlying the delusion but does not argue
with it. Option 3 avoids the client. Option 2 places the client in a position that requires a response. Option
1 is an attempt to convince the client to believe another thought. This response may cause the client to hold
the delusion more strongly.

168. Correct Answer : 4

Rationale: Safety of the client, other clients, and staff is of prime concern. Option 1 is not appropriate,
given the fact that the client is inebriated and may not be able to be reasoned with. Option 2 is inaccurate
because waiting to intervene could cause the client to become even more agitated and a threat to others.
Option 3 would further aggravate an already agitated individual. Option 4 is in effect an isolation
technique that allows for separation from others and provides a less stimulating environment where the
client can maintain dignity.

169. Correct Answer : 2

Rationale: Denial is refusal to admit to a painful reality, which is treated as if it does not exist. In
projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other
people, objects, or situations. In regression, the client returns to an earlier, more comforting, although less
mature way of behaving. Rationalization is justifying illogical or unreasonable ideas, actions, or feelings
by developing acceptable explanations that satisfy the teller as well as the listener.

170. Correct Answer : 4

Rationale: Most suicides occur within 3 months after the beginning of the improvement, when the client
has the energy to carry out the suicidal intentions. Options 1, 2, and 3 are incorrect.

171. Correct Answer : 4

Rationale: Ego defense mechanisms are operations outside a person's awareness that the ego calls into
play to protect against anxiety. Displacement is the discharging of pent up feelings on persons less
dangerous than those who initially aroused the emotion. Denial is the blocking out of painful or anxiety-
inducing events or feelings. Repression is unconsciously keeping unacceptable feelings out of awareness.
Suppression is consciously keeping unacceptable feelings and thoughts out of awareness.

172. Correct Answer : 1

Rationale: Restating is the therapeutic communication technique in which the nurse repeats what the
client says to show understanding and to review what was said. Option 1 uses the therapeutic technique of
restating. In option 2, the nurse attempts to use focusing, but the attempt to discuss central issues is
premature. In option 3, the nurse makes a judgment and is nontherapeutic in the one-to-one relationship. In
option 4, the nurse is attempting to assess the client's ability to openly discuss feelings with family
members.

173. Correct Answer : 4

Rationale: Generally, voluntary admission is sought by the client. A voluntary admission permits a
client to make a written application for admission. If the client seeks voluntary admission, the most likely
expectation is that the client will participate in the treatment program. Options 1, 2, and 3 are not
characteristics of this type of admission.

174. Correct Answer : 3

Rationale: Generally, voluntary admission is sought by the client. Voluntary clients have the right to
demand and obtain release. If the client is a minor, the release may be contingent on the consent of the
parents or guardian. The nurse needs to be familiar with the state and facility policies and procedures.
Many states require that the client submit a written release notice to the facility staff, who reevaluate the
client's condition for possible conversion to involuntary status, according to criteria established by laws.
The best nursing action is to contact the physician.

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175. Correct Answer : 1

Rationale: Involuntary admission is made without the client's consent. Involuntary admission is
necessary when a person is a danger to self or others or is in need of psychiatric treatment or physical care.
Options 2, 3, and 4 describe the process of voluntary admission.

176. Correct Answer : 3

Rationale: Clients who are involuntarily admitted do not lose their right to informed consent. Clients
must be considered legally competent until they have been declared incompetent through a legal
proceeding. The informed consent needs to be obtained from the client.

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177. Correct Answer : 2

Rationale: A client may request to be secluded or restrained. Federal laws require the consent of the
client, unless an emergency situation exists in which an immediate risk to the client or others can be
documented. The use of seclusion and restraint is permitted only on the written order of a physician, which
must be reviewed and renewed every 24 hours, and which also must specify the type of restraint to be
used.

178. Correct Answer : 2

Rationale: The nurse should never promise to keep a secret. Secrets are appropriate in a social
relationship but not in a therapeutic one. The nurse needs to be honest with the client and tell the client that
a promise cannot be made to keep the secret. Options 1, 3, and 4 are inappropriate responses.

179. Correct Answer : 2

Rationale: Depression may be a recurring illness for some persons. The client needs lo understand the
symptoms and recognize when treatment needs to begin again. Options 1, 3, and 4 indicate that the client
has learned some coping skills, such as setting limits and taking medications. Option 2 is an unrealistic
statement, indicating that further teaching is needed.

180. Correct Answer : 1

Rationale: The client in seclusion must be assessed at regular intervals (usually every 15 to 30 minutes)
for physical needs, safety, and comfort. Option 2 indicates a physical need that could be met with a urinal
or bedpan, if necessary; it does not indicate that the client has calmed down enough to leave the seclusion
room. Option 3 could be an attempt to manipulate the nurse. No indication is given that the client will
exercise self-control when alone in the room. Option 4 indicates the need for supportive communication or
possibly medication as needed; it does not necessitate discontinuing seclusion.

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