source: lippincott, mosby and incredibly easy nclex questionnaires

1. The nurse is caring for a client who experiences false sensory

perceptions with no basis in reality. These perceptions are known as:

a. delusions.
b. hallucinations.
c. loose associations.
d. neologisms.

RATIONALE: Hallucinations are visual, auditory, gustatory, tactile, or

olfactory perceptions that have no basis in reality. Delusions are false
beliefs, rather than perceptions, that the client accepts as real. Loose
associations are rapid shifts among unrelated ideas. Neologisms are
bizarre words that have meaning only to the client.

2. The nurse is caring for a client who is suicidal. When accompanying

the client to the bathroom, the nurse should:

a. give him privacy in the bathroom.

b. allow him to shave.
c. open the window and allow him to get some fresh air.
d. observe him.

RATIONALE: The nurse has a responsibility to observe continuously the

acutely suicidal client not provide privacy. The nurse should watch for
clues, such as communicating suicidal thoughts, threats, and
messages; hoarding medications; and talking about death. By
accompanying the client to the bathroom, the nurse will naturally
prevent hanging or other injury. The nurse will check the client's area
and fix dangerous conditions, such as exposed pipes and windows
without safety glass. The nurse will also remove potentially dangerous
objects, such as belts, razors, suspenders, glass, and knives.

3. The nurse is developing a care plan for a client with anorexia

nervosa. Which action should the nurse include in the plan?

a. Restrict visits with the family until the client begins to eat.
b. Provide privacy during meals.
c. Set up a strict eating plan for the client.
d. Encourage the client to exercise, which will reduce her anxiety.

RATIONALE: Establishing a consistent eating plan and monitoring the

client's weight are important for this disorder. The family should be
included in the client's care. The client should be monitored during
meals not given privacy. Exercise must be limited and supervised.
4. A client whose husband recently left her is admitted to the hospital
with severe depression. The nurse suspects that the client is at risk for
suicide. Which of the following questions would be most appropriate
and helpful for the nurse to ask during an assessment for suicide risk?

a. "Are you sure you want to kill yourself?"

b. "I know if my husband left me, I'd want to kill myself. Is that what
you think?"
c. "How do you think you would kill yourself?"
d. "Why don't you just look at the positives in your life?"

RATIONALE: To determine if a client is at risk for suicide, ask, "How do

you think you would kill yourself?" If the client has a plan, she may be
closer to carrying out the act. Option 1 requires a yes-or-no response
and is self-limiting. In option 2, the nurse is telling the client what to
think and feel. Option 4 dismisses the client's feelings

5. The nurse is caring for a client who she believes has been abusing
opiates. Assessment findings in a client abusing opiates, such as
morphine, include:

a. dilated pupils and slurred speech.

b. rapid speech and agitation.
c. dilated pupils and agitation.
d. euphoria and constricted pupils.

RATIONALE: Assessment findings in a client abusing opiates include

agitation, slurred speech, euphoria, and constricted pupils.

6. The nurse is caring for a client experiencing an anxiety attack.

Appropriate nursing interventions include:

a. turning on the lights and opening the windows so that the client
doesn't feel crowded.
b. leaving the client alone.
c. staying with the client and speaking in short sentences.
d. turning on stereo music.

RATIONALE: Appropriate nursing interventions for an anxiety attack

include using short sentences, staying with the client, decreasing
stimuli, remaining calm, and medicating as needed. Leaving the client
alone, turning on a stereo or lights, and opening windows may increase
the client's anxiety.

7. The nurse is teaching a new group of mental health aides. The nurse
should teach the aides that setting limits is most important for:

a. a depressed client.
b. a manic client.
c. a suicidal client.
d. an anxious client.

RATIONALE: Setting limits for unacceptable behavior is most important

in a manic client. Typically, depressed, anxious, or suicidal clients don't
physically or mentally test the limits of the caregiver.

8. A client is admitted with a diagnosis of delusions of grandeur. This

diagnosis reflects a belief that one is:

a. highly important or famous.

b. being persecuted.
c. connected to events unrelated to oneself.
d. responsible for the evil in the world.

RATIONALE: A delusion of grandeur is a false belief that one is highly

important or famous. A delusion of persecution is a false belief that
one is being persecuted. A delusion of reference is a false belief that
one is connected to events unrelated to oneself or a belief that one is
responsible for the evil in the world.

9. The nurse is caring for a client, a Vietnam veteran, who exhibits

signs and symptoms of posttraumatic stress disorder. Signs and
symptoms of posttraumatic stress disorder include:

a. hyperalertness and sleep disturbances.

b. memory loss of traumatic event and somatic distress.
c. feelings of hostility and violent behavior.
d. sudden behavioral changes and anorexia.

RATIONALE: Signs and symptoms of posttraumatic stress disorder

include hyperalertness, sleep disturbances, exaggerated startle,
survival guilt, and memory impairment. Also, the client relives the
traumatic event through dreams and recollections. Hostility, violent
behavior, and anorexia aren't usual signs or symptoms of
posttraumatic stress disorder

10. The nurse is caring for a client with manic depression. The care
plan for a client in a manic state would include:

a. offering high-calorie meals and strongly encouraging the client to

finish all food.
b. insisting that the client remain active throughout the day so that
he'll sleep at night.
c. allowing the client to exhibit hyperactive, demanding, manipulative
behavior without setting limits.
d. listening attentively with a neutral attitude and avoiding power
struggles.

RATIONALE: The nurse should listen to the client's requests, express

willingness to seriously consider the requests, and respond later. The
nurse should encourage the client to take short daytime naps because
he expends so much energy. The nurse shouldn't try to restrain the
client when he feels the need to move around as long as his activity
isn't harmful. High-calorie finger foods should be offered to supplement
the client's diet, if he can't remain seated long enough to eat a
complete meal. The client shouldn't be forced to stay seated at the
table to finish a meal. The nurse should set limits in a calm, clear, and
self-confident tone of voice

11. A client is a Vietnam War veteran with a diagnosis of posttraumatic

stress disorder. He has a history of nightmares, depression,
hopelessness, and alcohol abuse. Which option offers the client the
most lasting relief of his symptoms?

a. The opportunity to verbalize memories of trauma to a sympathetic

listener
b. Family support
c. Prescribed medications taken as ordered
d. Alcoholics Anonymous (AA) meetings

RATIONALE: Although it's difficult, clients with posttraumatic stress

disorder can obtain the most lasting relief if they verbalize memories
of the trauma to a sympathetic listener. Family members are
commonly frightened by the information and can't be consistently
supportive. Antidepressants may help but these drugs can mask
feelings and can't provide lasting relief. Treatment for alcohol abuse,
including AA meetings, must be considered when planning care but
alone doesn't provide lasting relief
12. A client is admitted for detoxification after a cocaine overdose. The
client tells the nurse that he frequently uses cocaine but that he can
control his use if he chooses. Which coping mechanism is he using?

a. Withdrawal
b. Logical thinking
c. Repression
d. Denial

RATIONALE: Denial is an unconscious defense mechanism in which

emotional conflict and anxiety is avoided by refusing to acknowledge
feelings, desires, impulses, or external facts that are consciously
intolerable. Withdrawal is a common response to stress, characterized
by apathy. Logical thinking is the ability to think rationally and make
responsible decisions, which would lead the client to admitting the
problem and seeking help. Repression is suppressing past events from
the consciousness because of guilty association

13. A 22-year-old client is diagnosed with dependent personality

disorder. Which behavior is most likely evidence of ineffective
individual coping?

a. Inability to make choices and decisions without advice

b. Showing interest only in solitary activities
c. Avoiding developing relationships
d. Recurrent self-destructive behavior with history of depression

RATIONALE: Individuals with dependent personality disorder typically

show indecisiveness, submissiveness, and clinging behaviors so that
others will make decisions for them. These clients feel helpless and
uncomfortable when alone and don't show interest in solitary activities.
They also pursue relationships in order to have someone to take care
of them. Although clients with dependent personality disorder may
become depressed and suicidal if their needs aren't met, this isn't a
typical response

14. A 38-year-old client is admitted for alcohol withdrawal. The most

common early sign or symptom that this client is likely to experience
is:

a. impending coma.
b. manipulating behavior.
c. suppression.
d. perceptual disorders.

RATIONALE: Perceptual disorders, especially frightening visual

hallucinations, are very common with alcohol withdrawal. Coma isn't
an immediate consequence. Manipulative behaviors are part of the
alcoholic client's personality but not a sign of alcohol withdrawal.
Suppression is a conscious effort to conceal unacceptable thoughts,
feelings, impulses, or acts and serves as a coping mechanism for most
alcoholics

15. A client is admitted with a diagnosis of schizotypal personality

disorder. Which signs would this client exhibit during social situations?

a. Aggressive behavior
b. Paranoid thoughts
c. Emotional affect
d. Independence needs

RATIONALE: Clients with schizotypal personality disorder experience

excessive social anxiety that can lead to paranoid thoughts.
Aggressive behavior is uncommon, although these clients may
experience agitation with anxiety. Their behavior is emotionally cold
with a flattened affect, regardless of the situation. These clients
demonstrate a reduced capacity for close or dependent relationships

16. The nurse is caring for a client in an acute manic state. What's the
most effective nursing action for this client?

a. Assigning him to group activities

b. Reducing his stimulation
c. Assisting him with self-care
d. Helping him express his feelings

RATIONALE: Reducing stimuli helps to reduce hyperactivity during a

manic state. Group activities would provide too much stimulation.
Trying to assist the client with self-care could cause increased
agitation. When in a manic state, these clients aren't able to express
their inner feelings in a productive, introspective manner. The focus of
treatment for a client in the manic state is behavior control

17. The nurse is caring for a client diagnosed with bulimia. The most
appropriate initial goal for a client diagnosed with bulimia is to:
a. avoid shopping for large amounts of food.
b. control eating impulses.
c. identify anxiety-causing situations.
d. eat only three meals per day.

RATIONALE: Bulimic behavior is generally a maladaptive coping

response to stress and underlying issues. The client must identify
anxiety-causing situations that stimulate the bulimic behavior and then
learn new ways of coping with the anxiety. Controlling shopping for
large amounts of food isn't a goal early in treatment. Managing eating
impulses and replacing them with adaptive coping mechanisms can be
integrated into the care plan after initially addressing stress and
underlying issues. Eating three meals per day isn't a realistic goal early
in treatment

18. The nurse is caring for a 40-year-old client. Which behavior by the
client indicates adult cognitive development?

a. Has perceptions based on reality

b. Assumes responsibility for actions
c. Generates new levels of awareness
d. Has maximum ability to solve problems and learn new skills

RATIONALE: Adults between ages 31 and 45 generate new levels of

awareness. Having perceptions based on reality and assuming
responsibility for actions indicate socialization development not
cognitive development. Demonstrating maximum ability to solve
problems and learning new skills occur in young adults between ages
20 and 30

19. A client with bipolar disorder is being treated with lithium for the
first time. The nurse should observe the client for which common
adverse effect of lithium?

a. Sexual dysfunction
b. Constipation
c. Polyuria
d. Seizures

RATIONALE: Polyuria commonly occurs early in the treatment with

lithium and could result in fluid volume deficit. Sexual dysfunction isn't
a common adverse effect of lithium; it's more common with sedatives
and tricyclic antidepressants. Diarrhea, not constipation, occurs with
lithium. Constipation can occur with other psychiatric drugs, such as
antipsychotic drugs. Seizures may be a later sign of lithium toxicity
20. A client is admitted for an overdose of amphetamines. When
assessing this client, the nurse should expect to see:

a. tension and irritability.

b. slow pulse.
c. hypotension.
d. constipation.

RATIONALE: An amphetamine is a nervous system stimulant that's

subject to abuse because of its ability to produce wakefulness and
euphoria. An overdose increases tension and irritability. Options B and
C are incorrect because amphetamines stimulate norepinephrine,
which increases the heart rate and blood flow. Diarrhea is a common
adverse effect, so option D is incorrect

21. During a shift report, the nurse learns that she'll be providing care
for a client who is vulnerable to panic attack. Treatment for panic
attacks includes behavioral therapy, supportive psychotherapy, and
medication such as:

a. barbiturates.
b. antianxiety drugs.
c. depressants.
d. amphetamines.

RATIONALE: Antianxiety drugs provide symptomatic relief. Barbiturates

and amphetamines can precipitate panic attacks. Depressants aren't
appropriate for treating panic attacks

22. A client comes to the emergency department while experiencing a

panic attack. The nurse can best respond to a client having a panic
attack by:

a. staying with the client until the attack subsides.

b. telling the client everything is under control.
c. telling the client to lie down and rest.
d. talking continually to the client by explaining what's happening.

RATIONALE: The nurse should remain with the client until the attack
subsides. If the client is left alone, he may become more anxious.
Giving false reassurance is inappropriate in this situation. The client
should be allowed to move around and pace to help expend energy.
The client may be so overwhelmed that he can't follow lengthy
explanations or instructions, so the nurse should use short phrases and
slowly give one direction at a time.

23. A 24-year-old client is experiencing an acute schizophrenic

episode. He has vivid hallucinations that are making him agitated. The
nurse's best response at this time would be to:

a. take the client's vital signs.

b. explore the content of the hallucinations.
c. tell him his fear is unrealistic.
d. engage the client in reality-oriented activities.

RATIONALE: Exploring the content of the hallucinations will help the

nurse understand the client's perspective on the situation. The client
shouldn't be touched, such as in taking vital signs, without telling him
exactly what's going to happen. Debating with the client about his
emotions isn't therapeutic. When the client is calm, engage him in
reality-based activities

24. A client with paranoid type schizophrenia becomes angry and tells
the nurse to leave him alone. The nurse should:

a. tell him that she'll leave for now but will return soon.
b. ask him if it's okay if she sits quietly with him.
c. ask him why he wants to be left alone.
d. tell him that she won't let anything happen to him.

RATIONALE: If the client tells the nurse to leave, the nurse should leave
but let the client know that she'll return so that he doesn't feel
abandoned. Not heeding the client's request can agitate him further.
Also, challenging the client isn't therapeutic and may increase his
anger. False reassurance isn't warranted in this situation

25. A client begins taking haloperidol (Haldol). After a few days, he

experiences severe tonic contractures of muscles in the neck, mouth,
and tongue. The nurse should recognize this as:

a. psychotic symptoms.
b. parkinsonism.
c. akathisia.
d. dystonia.
RATIONALE: These symptoms describe dystonia, which commonly
occurs after a few days of treatment with haloperidol. The symptoms
may be confused with psychotic symptoms and misdiagnosed.
Parkinsonism results in muscle rigidity, shuffling gait, stooped posture,
flat-faced affect, tremors, and drooling. Signs and symptoms of
akathisia are restlessness, pacing, and inability to sit still

26. The nurse must administer a medication to reverse or prevent

Parkinson-type symptoms in a client receiving an antipsychotic. The
medication the client will likely receive is:

a. benztropine (Cogentin).
b. diphenhydramine (Benadryl).
c. propranolol (Inderal).
d. haloperidol (Haldol).

RATIONALE: Benztropine, trihexyphenidyl, or amantadine is prescribed

for a client with Parkinson-type symptoms. Diphenhydramine provides
rapid relief for dystonia. Propranolol relieves akathisia. Haloperidol can
cause Parkinson-type symptoms

27. Which information is most important for the nurse to include in a

teaching plan for a schizophrenic client taking clozapine (Clozaril)?

a. Monthly blood tests will be necessary.

b. Report a sore throat or fever to the physician immediately.
c. Blood pressure must be monitored for hypertension.
d. Stop the medication when symptoms subside.

RATIONALE: A sore throat and fever are indications of an infection

caused by agranulocytosis, a potentially life-threatening complication
of clozapine. Because of the risk of agranulocytosis, white blood cell
(WBC) counts are necessary weekly, not monthly. If the WBC count
drops below 3,000/ml, the medication must be stopped. Hypotension
may occur in clients taking this medication. Warn the client to stand up
slowly to avoid dizziness from orthostatic hypotension. The medication
should be continued, even when symptoms have been controlled. If
the medication must be stopped, it should be slowly tapered over 1 to
2 weeks and only under the supervision of a physician

28. A client with manic episodes is taking lithium. Which electrolyte

level should the nurse check before administering this medication?

a. Calcium
b. Sodium
c. Chloride
d. Potassium

RATIONALE: Lithium is chemically similar to sodium. When sodium

levels are reduced, such as from sweating or diuresis, lithium is
reabsorbed by the kidneys, increasing the risk of toxicity. Clients
taking lithium shouldn't restrict their intake of sodium and should drink
adequate amounts of fluid each day. The other electrolytes are
important for normal body functions, but sodium is most important to
the absorption of lithium

29. A client is admitted to the inpatient unit of the mental health

center with a diagnosis of paranoid schizophrenia. He's shouting that
the government of France is trying to assassinate him. Which of the
following responses is most appropriate?

a. "I think you're wrong. France is a friendly country and an ally of the
United States. Their government wouldn't try to kill you."
b. "I find it hard to believe that a foreign government or anyone else is
trying to hurt you. You must feel frightened by this."
c. "You're wrong. Nobody is trying to kill you."
d. "A foreign government is trying to kill you? Please tell me more
about it."

RATIONALE: Responses should focus on reality while acknowledging

the client's feelings. Arguing with the client or denying his belief isn't
therapeutic. Arguing can also inhibit development of a trusting
relationship. Continuing to talk about delusions may aggravate the
psychosis. Asking the client if a foreign government is trying to kill him
may increase his anxiety level and can reinforce his delusions

30. A client has been receiving chlorpromazine (Thorazine), an

antipsychotic, to treat his psychosis. Which finding should alert the
nurse that the client is experiencing pseudoparkinsonism?

a. Restlessness, difficulty sitting still, pacing

b. Involuntary rolling of the eyes
c. Tremors, shuffling gait, masklike face
d. Extremity and neck spasms, facial grimacing, jerky movements

RATIONALE: Pseudoparkinsonism may appear 1 to 5 days after starting

an antipsychotic and may also include drooling, rigidity, and pill rolling.
Akathisia may occur several weeks after starting antipsychotic therapy
and consists of restlessness, difficulty sitting still, and fidgeting. An
oculogyric crisis is recognized by uncontrollable rolling back of the
eyes and, along with dystonia, should be considered an emergency.
Dystonia may occur minutes to hours after receiving an antipsychotic
and may include extremity and neck spasms, jerky muscle
movements, and facial grimacing

31. A 54-year-old female was found unconscious on the floor of her

bathroom with self-inflicted wrist lacerations. An ambulance was called
and the client was taken to the emergency department. When she was
stable, the client was transferred to the inpatient psychiatric unit for
observation and treatment with antidepressants. Now that the client is
feeling better, which nursing intervention is most appropriate?

a. Observing for extrapyramidal symptoms

b. Beginning a therapeutic relationship
c. Canceling any no-suicide contracts
d. Continuing suicide precautions

RATIONALE: As antidepressants begin to take effect and the client feels

better, she may have the energy to initiate and complete another
suicide attempt. As the client's energy level increases, the nurse must
continue to be vigilant to the risk of suicide. Extrapyramidal symptoms
may occur with antipsychotics and aren't adverse effects of
antidepressants. A therapeutic relationship should be initiated upon
admission to the psychiatric unit, after suicide precautions have been
instituted. It's through this relationship that the client develops feelings
of self-worth and trust and problem-solving takes place. In a no-suicide
contract, the client states verbally or in writing that she won't attempt
suicide and will seek out staff if she has suicidal thoughts. When the
time period for a contract has expired, a new contract should be
obtained from the client

32. A 26-year-old male reports losing his sight in both eyes. He's
diagnosed as having a conversion disorder and is admitted to the
psychiatric unit. Which nursing intervention would be most appropriate
for this client?

a. Not focusing on his blindness

b. Providing self-care for him
c. Telling him that his blindness isn't real
d. Teaching eye exercises to strengthen his eyes

RATIONALE: Focusing on the client's blindness can positively reinforce

the blindness and further promote the use of maladaptive behaviors to
obtain secondary gains. The client should be encouraged to participate
in his own self-care as much as possible to avoid fostering
dependency. To promote self-esteem, give positive reinforcement for
what the client can do. Blindness and other physical symptoms in a
conversion disorder aren't under the client's control and are real to
him. Eye exercises won't resolve the client's blindness because no
organic pathology is causing the symptoms

33. A client has a diagnosis of borderline personality disorder. She has

attached herself to one nurse and refuses to speak with other staff
members. She tells the nurse that the other nurses are mean, withhold
her medication, and mistreat her. The staff is discussing this problem
at their weekly conference. Which intervention would be most
appropriate for the nursing staff to implement?

a. Provide an unstructured environment for the client.

b. Rotate the nurses who are assigned to the client.
c. Ignore the client's behaviors.
d. Bend unit rules to meet the client's needs.

RATIONALE: Rotating staff members who work with a client with a

borderline personality disorder keeps the client from becoming
dependent on any one nurse and reduces the use of splitting behaviors
and her fear of abandonment. Firm rules and consistency among staff
members will help control the client's behavior. Ignoring splitting
behaviors can cause the client to increase the behavior by trying to get
a response from the staff. Unit rules must be consistently enforced and
followed by each nurse to help the client control behavior

34. A client is being admitted to the substance abuse unit for alcohol
detoxification. As part of the intake interview, the nurse asks him when
he had his last alcoholic drink. He says that he had his last drink 6
hours before admission. Based on this response, the nurse should
expect early withdrawal symptoms to:

a. not occur at all because the time period for their occurrence has
passed.
b. begin anytime within the next 1 to 2 days.
c. begin within 2 to 7 days.
d. begin after 7 days.

RATIONALE: Acute withdrawal symptoms from alcohol may begin 6

hours after the client has stopped drinking and peak 1 to 2 days later.
Delirium tremens may occur 2 even up to 7 days after the last drink.

35. Which of the following factors would have the most influence on
the outcome of a crisis situation?

a. Age
b. Previous coping skills
c. Self-esteem
d. Perception of the problem

RATIONALE: Coping is a process by which a person deals with problems

using cognitive and noncognitive components. Cognitive responses
come from learned skills; noncognitive responses are automatic,
focusing on relieving the discomfort. Age could have either a positive
or negative effect during crisis, depending on previous experiences.
Previous coping skills are cognitive and include the thought and
learning necessary to identify the source of stress in a crisis situation.
Therefore, previous coping skills is the best answer. Although
sometimes useful, noncognitive measures, such as self-esteem, may
prevent the person from learning more about the crisis as well as a
better solution to the problem. The person involved could have correct
or incorrect perception of the problem that could have either a positive
or negative outcome

36. The nurse is caring for an elderly client in a long-term care facility.
The client has a history of attempted suicide. The nurse observes the
client giving away personal belongings and has heard the client
express feelings of hopelessness to other residents. Which intervention
should the nurse perform first?

a. Setting aside time to listen to the client

b. Removing items that the client could use in a suicide attempt
c. Communicating a nonjudgmental attitude
d. Referring the client to a mental health professional

RATIONALE: The nurse's first responsibility is to protect the client from

injuring himself. Listening and being nonjudgmental are important
elements of the nurse's communication with the client. After the
client's safety has been established, he would benefit from a referral to
a mental health professional

37. The nurse is caring for an adolescent female who reports

amenorrhea, weight loss, and depression. Which additional assessment
finding would suggest that the woman has an eating disorder?
a. Wearing tight-fitting clothing
b. Increased blood pressure
c. Oily skin
d. Excessive and ritualized exercise

RATIONALE: A client with an eating disorder will normally exercise to

excess in an effort to burn as many calories as possible. The client will
usually wear loose-fitting clothing to hide what she considers to be a
fat body. Skin and nails become dry and brittle, and blood pressure
and body temperature drop from excessive weight loss

38. A high school student is referred to the school nurse for suspected
substance abuse. Following the nurse's assessment and interventions,
what would be the most desirable outcome?

a. The student discusses conflicts over drug use.

b. The student accepts a referral to a substance abuse counselor.
c. The student agrees to inform his parents of the problem.
d. The student reports increased comfort with making choices.

RATIONALE: All of the outcomes stated are desirable; however, the

best outcome is that the student would agree to seek the assistance of
a professional substance abuse counselor

39. The nurse is using drawing, puppetry, and other forms of play
therapy while treating a terminally ill, school-age child. The purpose of
these techniques is to help the child:

a. internalize his feelings about death and dying.

b. accept responsibility for his situation.
c. express feelings that he can't articulate.
d. have a good time while he's in the hospital.

RATIONALE: Children may not have the verbal and cognitive skills to
express what they feel and may benefit from alternative modes of
expression. It's important for the child to find a way to express
internalized feelings. The child must also know that he isn't to blame
for this situation. In the process of doing play therapy, the child can
also have fun, but that isn't the main goal of therapy

40. The nurse is working with a client who abuses alcohol. Which of the
following facts should the nurse communicate to the client?

a. Abstinence is the basis for successful treatment.

b. Attendance at Alcoholics Anonymous (AA) meetings every day will
cure alcoholism.
c. For treatment to be successful, family members must participate.
d. An occasional social drink is acceptable behavior for the alcoholic.

RATIONALE: The foundation of any treatment for alcoholism is

abstinence. Attendance at AA is helpful to some individuals to maintain
strict abstinence. Participation in treatment by the family is beneficial
to both the client and the family but isn't essential. Abstinence requires
refraining from social drinking.

41. One staff member in a psychiatric unit says to the nurse, "Why are
we carrying out suicide precautions for someone who is dying? It's
pointless and a waste of time." The nurse should:

a. Assign the staff member to other clients.

b. Ask the psychiatric clinical nurse specialist to meet with the staff
member.
c. Agree with the staff member and discontinue suicide precautions.
d. Call for a multidisciplinary staff meeting.

RATIONALE: The nurse would call for a multidisciplinary staff meeting

because there is a need for staff members to share their feelings of
anger, frustration, and grief. Because nurses focus on saving human
lives, any feelings of hopelessness regarding a dying client can
interfere with the client's care and management. Assigning the staff
member to other clients ignores the staff's need to work through
feelings. Calling the clinical nurse specialist to deal with the staff
member does nothing to help the immediate situation. The psychiatric
clinical nurse specialist would be included in the staff meeting to help
the entire staff deal with their feelings. Agreeing with the staff member
and discontinuing suicide precautions is highly inappropriate.

42. The client with dual diagnoses of major depression and alcohol
abuse states, "I only drink when I can't sleep." An initial outcome for
this client is that the client will:

a. Describe adaptive methods of coping to induce sleep.

b. Verbalize negative effects of alcohol on the body.
c. Describe dangerous effects when combining alcohol and
antidepressant medication.
d. Verbalize the desire to stop drinking alcohol.

RATIONALE: Verbalizing the desire to stop drinking alcohol is an initial

outcome that acknowledges alcohol consumption as a problem
behavior and leads to further participation in treatment. Describing
adaptive methods to use instead of drinking alcohol to induce sleep is
an outcome to be reached later in the client's course of treatment.
Verbalizing the negative effects of alcohol on the body is a therapeutic
behavior but is not specific to helping the client sleep. Describing the
dangerous effects of using alcohol with antidepressant medication is a
therapeutic behavior but is not specific to helping the client sleep.

43. The nurse will conduct a psychoeducational group for family

members about depression. Which of the following topics would be of
little help to the family members?

a. Managing the depressed client at home.

b. Drug classifications.
c. Support and self-help groups.
d. Education about depression.

RATIONALE: Focusing on antidepressant medications would be helpful,

but the topic of drug classifications is too general. A topic such as
managing the depressed client at home will help family members learn
positive techniques for managing day-to-day problems and will
promote family cohesiveness. A topic such as receiving support from
self-help groups is helpful to family members to reduce feelings of
isolation and powerlessness. Educating the family about the illness
dispels myths, enlists family cooperation, and promotes adaptive
coping skills.

44. In teaching a client about Alcoholics Anonymous, the nurse states

that Alcoholics Anonymous has helped in the rehabilitation of many
alcoholics, probably because many people find it easier to change their
behavior when they:

a. Have the support of rehabilitated alcoholics.

b. Know that rehabilitated alcoholics will sympathize with them.
c. Can depend on rehabilitated alcoholics to help them identify
personal problems related to alcoholism.
d. Realize that rehabilitated alcoholics will help them develop defense
mechanisms to cope with their alcoholism.

RATIONALE: Membership in Alcoholics Anonymous is voluntary. Its

rehabilitated members are available to support alcoholics, and the
understanding and influence of these rehabilitated members often
helps alcoholics change their behavior. The role of rehabilitated
members does not include sympathizing with others abusing alcohol.
The role of rehabilitated members does not include helping others
abusing alcohol to identify personal problems. The role of rehabilitated
members does not include helping others abusing alcohol to develop
defense mechanisms to cope with alcoholism.

45. A client walks into the mental health clinic and states to the nurse,
"I guess I can't make it without my wife. I can't even sleep without
her." Which of the following responses by the nurse would be most
therapeutic?

a. "Things always look worse before they get better."

b. "I'd say that you're not giving yourself a fair chance."
c. "I'll ask the doctor for some sleeping pills for you."
d. "Tell me more about what you mean when you say you can't make it
without your wife."

RATIONALE: The nurse helps the client explore his feelings by

expressing interest in knowing more about his problem in order to
make an accurate assessment. Cliches minimize the client's feelings
and block expression. Statements that make unwarranted judgments
about the client block communication and may suggest that he should
feel guilty for his feelings. The nurse has not explored the client's
feelings or made any assessment. Asking the doctor for sleeping pills
reflects poor judgment based on insufficient assessment data. Sleeping
pills may be inappropriate and not therapeutic for this client.

46. During the conversation with the nurse, a victim of physical abuse
says, "Let me try to explain why I stay with my husband." Which of the
following reasons would the client be LEAST likely to mention?

a. "I'm responsible for keeping my family together."

b. "When it's not too bad, the abuse adds spice to our relationship."
c. "I love my husband."
d. "I'm not sure I could get a job that pays even minimum wage."

RATIONALE: Violence is never acceptable to a victim; this myth

condones the use of violence. Often, an episode of battering is
followed by a period of pleasant relations between the partners, during
which the victim may hope that the violence will never happen again.
The victim may stay in the relationship for that reason.Women are
conditioned to be responsible for the family's well-being. This is often a
motivation for a battered woman to stay in an abusive relationship.
The victim believes that she can save the relationship and that her
partner will change. Feelings of guilt surrounding issues such as these
often influence an abused woman's decisions about staying with her
partner. A woman's lack of job skills and financial resources may cause
her to stay. Many women are injured or killed when they try to leave in
a violent relationship.

47. During a home visit, the client tells the nurse she's not taking
prescribed doses of haloperidol (Haldol) because she's tired of
bothering with it and doesn't need it. The nurse's best action is to:

a. Explain the negative effects of skipping the medication.

b. Consult with the physician about changing the medication to
haloperidol decanoate (Haldol Decanoate) injections.
c. Have the client's family begin commitment procedures so that her
medication regimen can be supervised more closely.
d. Refer the client to a partial hospitalization program so that she can
participate regularly in group therapy sessions.

RATIONALE: For the client who is noncompliant with oral medication,

depot medication is advantageous because the client will only need to
keep one appointment every 2 to 4 weeks instead of taking medication
daily. Education may or may not affect the client's compliance with
medication. Long-term commitment is unnecessary at this time.
Participation in a partial hospitalization program may be a desirable
referral but would only indirectly affect the client's compliance with
medication.

48. The client has been taking the monoamine oxidase inhibitor (MAOI)
phenelzine (Nardil), 10 mg bid. The physician orders a selective
serotonin reuptake inhibitor (SSRI), paroxetine (Paxil), 20 mg given
every morning. The nurse:

a. Gives the medication as ordered.

b. Questions the physician about the order.
c. Questions the dosage ordered.
d. Asks the physician to order benztropine (Cogentin) for the side
effects.

RATIONALE: The nurse questions the physician about the order

because the client who has been taking an MAOI such as phenelzine
must wait 14 days after stopping the MAOI before starting an SSRI
such as paroxetine. Serotonin syndrome, a potentially lethal
consequence, can occur when combining an MAOI and an SSRI.
Serotonin syndrome is characterized by hyperreflexia, hyperthermia,
myoclonus, and other symptoms similar to neuroleptic malignant
syndrome. Giving the medication as ordered can result in serious
adverse consequences, as described above.

The dosage is accurate. Benztropine is not given with an SSRI; it is an

antiparkinsonian agent usually ordered for the side effects of
antipsychotic medication.

49. A voluntary client has been taking haloperidol (Haldol) as

prescribed. One morning, she refuses to take the Haldol. Which of the
following actions should the nurse take?

a. Summon another nurse to help ensure that the client takes her
medicine.
b. Tell the client that she can take the medication either orally or by
injection.
c. Withhold the medication until it is determined why the client is
refusing to take it.
d. Tell the client that she needs to take her "vitamin" to stay healthy.

RATIONALE: The client has a legal right to refuse treatment. When a

client refuses medication, the nurse must explore the reason for the
refusal. The desire to avoid unwanted side effects is a common reason.
Legally a client cannot be forcibly medicated unless she is a danger to
herself or others or there is a court order to treat. Legally a client
cannot be forcibly medicated unless she is a danger to herself or
others or there is a court order to treat. Lying to a client about a
medication is neither appropriate nor ethical.

50. The client is taking fluoxetine (Prozac) 20 mg at bedtime. He states

that Prozac is not helping him to sleep. The nurse judges:

a. That the client should take Prozac in the morning.

b. That dose is too high.
c. That the client's symptoms of depression seem to be getting worse.
d. That the client is on the wrong medication.

RATIONALE: Fluoxetine should be taken as early in the day as possible

so as not to interfere with nighttime sleep; it may cause nervousness
in some clients. The dose is therapeutic and not too high. There is no
evidence in this situation to justify the conclusion that the client's
depression is worsening. There is no evidence in this situation to justify
the conclusion that the client is on the wrong medication.
the complete 100 items copy is posted at http://stuffednurse-
elite.blogspot.com (a members only site)