ATI Pediatrics Practice Exam With Answers-250 Solved Questions

ATI - Pediatrics ATI questions all
Pediatrics (Chamberlain University)
1. A nurse is caring for a client who is dying. The client says, "My mother died in the hospital,
but I did not get there before she died." Which of the following statements should the nurse
make?
A. "We will call your family in time for them to get here."
B. "I wonder if you are fearful of dying alone."
C. "I will make sure a staff member is in your room at all times."
D. "I will tell your family of your concern so that they can be here."
Answer: B. "I wonder if you are fearful of dying alone."
Rationale:
A. The nurse dismisses the client’s concerns and gives false reassurance.
B. The nurse dismisses the client’s concerns and gives false reassurance.
C. The nurse dismisses the client’s concerns and gives false reassurance.
D. The nurse dismisses the client’s concerns and gives false reassurance.
2. A nurse is caring for a young adult client who says he is experiencing increased anxiety and an
inability to concentrate. Which of the following responses should the nurse make?
A. "It sounds like you're having a difficult time."
B. "Have you talked to your parents about this yet?"
C. "Why do you think you are so anxious?"
D. "How long has this been going on?"
Answer: A. "It sounds like you're having a difficult time."
Rationale:
A. This therapeutic response is an open-ended, empathetic statement that encourages the client to
talk.
B. This nontherapeutic response is focused inappropriately on the client's parents. It does not
address the client's need to communicate or express feelings.
C. This nontherapeutic response can make the client feel defensive, and he might not be able to
tell the nurse why.

D. This nontherapeutic response is a closed-ended statement that does not encourage the client to
talk.
3. A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should
plan to make which of the following room assignments for the client?
A. A private room in a quiet location on the unit
B. A semi-private room with a roommate who has a similar diagnosis
C. A private room close to the nursing station
D. A seclusion room until the client’s activity level becomes more subdued.
Answer: A. A private room in a quiet location on the unit
Rationale:
A. A private room in a quiet location is ideal for a client with mania. The client may easily
become overstimulated by the number of people and activities in a nursing care unit. A private
room can be used for time-out during the day and to settle down to sleep at night.
B. The client should not be given a semi-private room with a roommate who is also experiencing
mania because the situation would be too stimulating for each of them.
C. The client should not be given a private room close to the nursing station because of the high
level of activity in that area.
D. Legal and ethical guidelines require treatment in the least restrictive setting. Seclusion
requires a provider’s s order and can only be used when there is a specific, documented need to
do so.
4. A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3
months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects
of care should the nurse consider the first priority for this client?
A. Identify the client's nutritional status.
B. Request a mental health consult.
C. Plan a therapeutic diet for the client.
D. Provide a structured environment for the client.
Answer: A. Identify the client's nutritional status.
Rationale:

A. According to the nursing process, the nurse should perform an assessment first to gather
enough data regarding nutritional status and other findings in order to plan, implement, and
evaluate care. The assessment identifies client nutrition needs as well as complications the client
might be experiencing related to the eating disorder.
B. Requesting a mental health consult might be necessary but another aspect of care is the
priority.
C. Planning a therapeutic diet for the client will be necessary but another aspect of care is the
priority.
D. It is important to provide a structured environment for the client regarding meals, times for
weighing, and monitoring of eating, but another aspect of care is the priority.
5. A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated
PRN for agitation with haloperidol. The nurse should assess the client for which of the following
adverse effects?
A. Dysrhythmias
B. Cataracts
C. Pancreatitis
D. Bleeding
Answer: A. Dysrhythmias
Rationale:
A. Cardiac dysrhythmias are a risk for clients taking haloperidol and other conventional
antipsychotic medications. The client should be monitored for changes in vital signs, tachycardia,
and ECG changes, including prolonged QT interval, while taking haloperidol. There is a risk for
cardiac arrest due to torsades de pointes.
B. The client who takes haloperidol is at risk for glaucoma, but cataracts are not an adverse
effect.
C. The client who takes haloperidol is at risk for hepatitis, but pancreatitis is not an adverse
effect.
D. The client who takes haloperidol does not have an increased risk for bleeding.

6. A client becomes very dejected and states, "No one really cares what happens to me. Life isn't
worth living anymore." Which of the following responses should the nurse make?
A. "Of course people care. Your family comes to visit every day."
B. "Why do you feel that way?"
C. "Tell me who you think doesn't care about you."
D. "I care about you, and I am concerned that you feel so sad."
Answer: D. "I care about you, and I am concerned that you feel so sad."
Rationale:
A. Trying to convince the client that his family members care about him is false reassurance that
minimizes the feelings he just communicated.
B. Asking the client a "why" question minimizes his feelings and is nontherapeutic.
C. By asking the client to tell what people don't care about him, the nurse is challenging the
client's beliefs and changing the focus of the client away from his feelings and onto another
subject.
D. This is an open-ended therapeutic statement that focuses on the client's feelings, shows
empathy, and allows for further exploration of the client's belief that life is not worth living in
order to keep the client safe from suicidal thoughts.
7. A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The
client received a telephone call that was upsetting, and now the client is pacing up and down the
corridors of the unit. Which of the following actions should the nurse take?
A. Instruct the client to sit down and stop pacing.
B. Allow the client to pace alone until physically tired.
C. Have a staff member escort the client to her room.
D. Walk with the client at a gradually slower pace.
Answer: D. Walk with the client at a gradually slower pace.
Rationale:
A. The client is experiencing severe or panic-level anxiety and in this condition has difficulty
comprehending instructions.

B. Not intervening for the client's pacing and allowing it to continue could be a safety hazard for
the client and other clients in the area. The nurse should take measures to reduce the client's
anxiety.
C. The client is experiencing severe or panic-level anxiety and should not be left alone to rest.
D. When the client is experiencing increased anxiety, it is important for the nurse to remain with
the client and promote a calm atmosphere. By walking with the client at a gradually slowing
pace, the nurse provides gross motor activity as an anxiety outlet that helps to calm the client and
demonstrates therapeutic offering of self.
8. A nurse is caring for a client who was involved in heavy combat and observed war casualties.
The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if
the client makes which of the following statements?
A. "I check any room I enter because the enemy is still after me and could be hiding anywhere."
B. "My child was born with a birth defect due to an exposure I had overseas."
C. "I killed four enemy soldiers with my bare hands and saved my entire battalion."
D. "In my dreams, all I can see are the wounded reaching out and trying to grab me."
Answer: D. "In my dreams, all I can see are the wounded reaching out and trying to grab me."
Rationale:
A. This client is making a paranoid statement, something more typical of a client who has
persecutory delusions. This statement is not characteristic of a client who has PTSD.
B. This statement is not characteristic of a client who has PTSD.
C. This client is making a grandiose statement, something more typical of a client who has
bipolar disorder in the manic phase. This statement is not characteristic of a client who has
PTSD.
D. Many clients who have PTSD repeatedly re-experience the ordeal in the form of flashback
episodes, memories, nightmares, or frightening thoughts, especially when they are exposed to
events or objects reminiscent of the trauma. This client's statement about haunting dreams is
typical of a client who has PTSD.
9. A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which
of the following comments made by the adolescent should be the nurse's priority to address?

A. "My parents treat me like a baby sometimes."
B. "I haven't gotten my period yet, and all my friends have theirs."
C. "None of the kids at this school like me, and I don't like them either."
D. "There's a big pimple on my face, and I worry that everyone will notice it."
Answer: C. "None of the kids at this school like me, and I don't like them either."
Rationale:
A. The nurse should further explore this comment with the client but it does not indicate the
greatest risk.
B. There is a wide variation in maturation among adolescents, who often feel inferior if they are
not maturing at the same pace as their peers. It is considered an expected finding for a 13-yearold female to not have reached menarche. This comment should concern the nurse but it does not
indicate the greatest risk to the client.
C. This comment indicates the client might be at risk for depression, an eating disorder, or selfharm. Therefore, this comment is the priority for the nurse to address.
D. The nurse should further explore this comment, as it might indicate the client has a problem
with her body image. However, it does not indicate the greatest risk to the client. Young
adolescents especially think that everyone is looking at them and seeing all their imperfections. It
is difficult for them to learn to deal with this and can be a major crisis for them as they learn to
deal with acceptance of themselves.
10. A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer’s
disease. Which of the following interventions should the nurse include in the plan?
A. Rotate assignment of daily caregivers.
B. Provide an activity schedule that changes from day to day.
C. Limit time for the client to perform activities.
D. Talk the client through tasks one step at a time.
Answer: D. Talk the client through tasks one step at a time.
Rationale:
A. The nurse should assign the same staff whenever possible to care for the client to minimize
confusion and ensure continuity of care for the client.

B. The nurse should provide a structured schedule of activities that does not change from day to
day to decrease the client's confusion.
C. The nurse should allow plenty of time for the client to perform activities to increase comfort
and decrease the client's anxiety level.
D. The nurse should plan to talk the client through tasks one step at a time to minimize confusion
and promote independence, which will decrease the client's anxiety level.
11. A nurse is providing discharge teaching to a client who has bipolar disorder and will be
discharged with a prescription for lithium. The nurse should teach the client that which of the
following factors puts her at risk for lithium toxicity?
A. The client runs 4 miles outdoors every afternoon.
B. The client drinks 2 liters of liquids daily.
C. The client eats 2 to 3 gm of sodium-containing foods daily.
D. The client eats foods high in tyramine.
Answer: A. The client runs 4 miles outdoors every afternoon.
Rationale:
A. Strenuous exercise in outdoor heat, which can lead to dehydration, puts the client at risk for
lithium toxicity. Mild to moderate exercise will not lead to lithium toxicity, but if the client
engages in strenuous exercise during hot weather, she should take care to replace any water and
sodium that have been lost through profuse sweating. This also applies to other factors that can
cause the client to become dehydrated, such as having diarrhea or taking diuretics.
B. Drinking 2 to 3 L of liquid daily can help prevent lithium toxicity by promoting normal
excretion of lithium from the body.
C. Although 2 to 3 gm of sodium-containing foods is above recommended nutrition guidelines,
this amount of sodium does not put the client at risk for lithium toxicity. Eating a diet with
consistent and adequate amounts of sodium is important for a client who takes lithium. A very
low-sodium diet prevents normal excretion of lithium from the body and can cause lithium
toxicity. A high sodium intake will lead to excretion of lithium and a possible drop in lithium
level. The client should be taught to eat an adequate, stable amount of sodium and not to greatly
decrease or increase sodium intake.

D. Foods high in tyramine interact with moon amine oxidase inhibitors which are prescribed for
depressive disorders. Tyramine does not affect lithium levels.
12. A nurse is providing teaching for a client who has binge-eating disorder and is morbidly
obese. The client has been prescribed orlistat. Which of the following statements indicates to the
nurse that the client understands the teaching?
A. "I will take my dose of orlistat every morning an hour before breakfast."
B. "I will eat a no-fat diet to prevent side effects from the medication."
C. "I will stop taking orlistat and call my doctor if my urine gets darker in color."
D. "I will feel less hungry during meals while I am taking orlistat."
Answer: C. "I will stop taking orlistat and call my doctor if my urine gets darker in color."
Rationale:
A. Orlistat, a lipase inhibitor, is used as an aid to help clients who are morbidly obese to lose
weight. Orlistat prevents the absorption of some of the fat in the client's dietary intake at each
meal. Therefore, the client should take the medication 3 times daily, during or within 1 hr after
the meal.
B. Consuming too little fat may lead to the client not getting enough nutrients, especially fatsoluble vitamins, from the diet. Instead, the client should eat a well-balanced, low-calorie,
nutritious diet with approximately 30% of calories consisting of fat calories.
C. Orlistat can cause severe liver damage; therefore, the client should be taught manifestations of
liver damage, including dark-colored urine, light-coloured stools, jaundice, anorexia, vomiting,
and fatigue.
D. Orlistat works by preventing absorption of dietary fat and is not an appetite suppressant.
13. A nurse is caring for a client who has major depressive disorder and was prescribed
citalopram 2 weeks ago with a planned dosage increase 1 week ago. The client reports having an
improved appetite, but still feels very depressed and is still having trouble sleeping. Which of the
following actions should the nurse take?
A. Speak to the provider about adding an MAOI to the current medication regimen.
B. Explain that antidepressants often take several weeks to be fully effective.
C. Tell the client that the provider will need to change citalopram to a different medication.

D. Recommend a sleep study be done on the client.
Answer: B. Explain that antidepressants often take several weeks to be fully effective.
Rationale:
A. Giving a SSRI along with an MAOI is contraindicated due to a greatly increased risk for
serotonin syndrome.
B. SSRIs are used along with certain anticonvulsant medications in the treatment of bipolar
disorder. It can take 4 to 6 weeks before therapeutic effects occur after beginning an
antidepressant medication.
C. It would be inappropriate for the nurse to tell the client that citalopram needs to be changed to
a different prescription. The nurse should teach the client about expected effects of citalopram.
D. Recommending a sleep study is not appropriate at this time until therapeutic effects of the
medication are known. The nurse should teach the client about expected effects of citalopram.
14. A nurse is caring for a client who was admitted with acute psychosis and is being treated with
haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia
when the client exhibits which of the following? (Select all that apply.)
A. Urinary retention and constipation
B. Tongue thrusting and lip smacking
C. Fine hand tremors and pill rolling
D. Facial grimacing and eye blinking
E. Involuntary pelvic rocking and hip thrusting movements
Answer: B. Tongue thrusting and lip smacking
D. Facial grimacing and eye blinking
E. Involuntary pelvic rocking and hip thrusting movements
Rationale:
A. Urinary retention and constipation is incorrect. Haloperidol can cause anticholinergic effects,
such as dry mucous membranes, urinary retention, and constipation. However, these are not
manifestations of tardive dyskinesia.
B. Tongue thrusting and lip smacking is correct. Individuals who have tardive dyskinesia make
repetitive and uncontrollable movements such as tongue thrusting and lip smacking.

C. Fine hand tremors and pill rolling is incorrect. The side effects of haloperidol can include
extrapyramidal (parkinsonian) symptoms, such as fine hand tremors and pill rolling. However,
these are not manifestations of tardive dyskinesia.
D. Facial grimacing and eye blinking is correct. Individuals who have tardive dyskinesia make
repetitive and uncontrollable movements such as facial grimacing and eye blinking.
E. Involuntary pelvic rocking and hip thrusting movements is correct. Repetitive, irregular, and
involuntary movements of the head, neck, trunk, and extremities can occur in tardive dyskinesia.
15. A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The
client comes to the nurse's station at 0300 demanding that the nurse call the provider
immediately. Which of the following responses by the nurse is appropriate?
A. "You are being unreasonable, and I will not call your doctor at this hour."
B. "Go back to your room, and I'll try to get in touch with your doctor."
C. "I can't call a doctor in the middle of the night unless it's an emergency."
D. "You must be very upset about something."
Answer: D. "You must be very upset about something."
Rationale:
A. This response by the nurse shows disapproval and is therefore nontherapeutic.
B. This response puts the client's feelings on hold and is therefore nontherapeutic.
C. This response by the nurse puts the client's feelings on hold and is therefore nontherapeutic.
D. This therapeutic response allows the nurse to show empathy for the client's feelings. The
response is also open-ended, which allows for further communication and encourages the client
to clarify the situation.
16. A nurse caring for a client who has depression observes the client comes to breakfast freshly
bathed, wearing clean clothes, and with combed and styled hair. Which of the following
responses by the nurse is therapeutic?
A. "Everyone feels better after showering."
B. "You must be getting better. You look great!"
C. "I see you have done some grooming today."
D. "Why are you all dressed up today? Is it a special occasion?"

Answer: C. "I see you have done some grooming today."
Rationale:
A. This response is nontherapeutic because it involves stereotyping.
B. This response is nontherapeutic because it makes assumptions about the client and shows
approval.
C. This response is open-ended, and this response is therapeutic because it offers the client
recognition of positive behavior and encourages further discussion.
D. This response is nontherapeutic because asking "why" questions can cause the client to feel
defensive.
17. A nurse is caring for a client who has schizophrenia and tells the nurse, "They lie about me
all the time and they are trying to poison my food." Which of the following statements should the
nurse make?
A. "You are mistaken. Nobody is lying about you or trying to poison you."
B. "You seem to be having very frightening thoughts."
C. "Why do you think you are being lied about and poisoned?"
D. "Who is lying about you and trying to poison you?"
Answer: B. "You seem to be having very frightening thoughts."
Rationale:
A. This statement is a nontherapeutic response because it directly contradicts the client's
delusional thinking, which could make the client feel angry and misunderstood.
B. When responding to a client who is delusional, the nurse should avoid making statements that
directly confront or affirm the client's delusional beliefs. Instead of responding literally to the
client's words, the nurse should respond to the feelings that the client is attempting to
communicate. By doing this, the nurse is shifting the focus from the delusional beliefs, which are
not real, to the client's fear, which is real.
C. This statement is a nontherapeutic response because it supports the content of the client's
delusional thinking. Asking a client “why” can cause the client to become defensive.
D. This statement is a nontherapeutic response because it supports the content of the client's
delusional thinking.

18. A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and
will be discharged with a prescription for lithium. The nurse's discharge teaching should include
information cautioning against which of the following factors that may cause lithium toxicity?
A. Experiencing diarrhea
B. Exercising moderately
C. Increasing sodium intake
D. Drinking green tea
Answer: A. Experiencing diarrhea
Rationale:
A. Lithium is used to treat the manic stage of bipolar disorder. Toxicity occurs when the level of
lithium in the blood becomes too high. A low sodium level, or factors which result in a low
sodium level, (such as dehydration, diarrhea, sweating, excess exercise in hot weather, diuretic
use, a low sodium diet) increases the lithium level because the kidney processes sodium and
lithium in the same way. If sodium levels fall, the body conserves lithium, causing lithium levels
to rise.
B. Moderate exercise should not lead to lithium toxicity.
C. Increasing sodium intake will lead to excretion of lithium and a drop in the lithium level.
D. Both green and black tea can lower lithium levels, making it less effective.
19. A nurse in an emergency department is caring for an adolescent client who reports being
sexually assaulted just prior to admission. Which of the following actions should the nurse take?
A. Discuss self-defence techniques with the client.
B. Inform the client photographs of injuries are required for a police report.
C. Ask the client to describe the situation.
D. Give the client a bed bath prior to physical examination.
Answer: C. Ask the client to describe the situation.
Rationale:
A. During the acute phase following sexual assault, the nurse should avoid implying the client
could have done something different, which could cause the client to assume guilt for the
situation.

B. The nurse should encourage the client to allow photographs of injuries as evidence to include
in a police report, but it is not required. The nurse must obtain client consent before taking
photographs.
C. During the acute phase following assault, the nurse should encourage the client to provide
information which may be helpful with treatment and to reduce the client’s anxiety.
D. The nurse should check the client for acute injuries that require medical attention. The nurse
can offer to assist the client with a bath or shower after physical examination and collection of
evidence.
20. A nurse in an emergency department is assessing a client who has been taking haloperidol for
3 months. The client has a temperature of 39.5° C (103.4° F), blood pressure of 150/110 mm Hg,
and muscle rigidity. Which of the following complications should the nurse suspect?
A. Agranulocytosis
B. Neuroleptic malignant syndrome
C. Akathisia
D. Tardive dyskinesia
Answer: B. Neuroleptic malignant syndrome
Rationale:
A. The nurse should suspect agranulocytosis if a client reports flulike manifestations and has a
decreased white blood cell count.
B. Neuroleptic malignant syndrome (NMS) is a rare and potentially fatal adverse effect of
antipsychotic medications that requires emergency medical intervention. Manifestations of NMS
are sudden and include changes in level of consciousness, seizures, and stupor.
C. The nurse should suspect akathisia if the client exhibits motor restlessness, such as foot
tapping or constantly shifting weight back and forth.
D. The nurse should suspect tardive dyskinesia if the client exhibits involuntary muscular
movements.
21. A nurse in a mental health facility is planning care for a client who has obsessive-compulsive
disorder (OCD) and is newly admitted to the unit. Which of the following actions should the
nurse plan to take regarding the client's compulsive behaviors?

A. Isolate the client for a period of time.
B. Confront the client about the senseless nature of the repetitive behaviors.
C. Plan the client’s schedule to allow time for rituals.
D. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.
Answer: C. Plan the client’s schedule to allow time for rituals.
Rationale:
A. Because OCD is an anxiety disorder, the nurse should offer presence, and take action to help
the client feel safe and secure.
B. The nurse should assist the client in identifying the meaning behind his behaviors to help the
client change his actions.
C. OCD is an anxiety disorder characterized by recurrent patterns of behavior a client feels
driven to perform. This behavior can be a physical action or a mental act that is aimed at
neutralizing anxiety or distress. In the initial phase of treatment, the nurse should allow adequate
time for the client to perform rituals to help the client handle anxiety.
D. The nurse should provide a structured, flexible environment initially, and gradually increase
limits on client behavior as the client’s anxiety becomes more manageable.
22. A nurse in a psychiatric unit is caring for several clients. Which of the following clients
should the nurse recommend for group therapy?
A. A client who has been taking amitriptyline for 3 months for depression
B. A client exhibiting psychotic behavior
C. A client admitted 12 hr ago for acute mania
D. A client who is experiencing alcohol intoxication
Answer: A. A client who has been taking amitriptyline for 3 months for depression
Rationale:
A. Psychotherapy groups provide clients with the opportunity to enhance their personal
relationships, increase self-awareness, and try new behaviors in a safe social setting.
Amitriptyline can take 4 to 8 weeks to become effective; therefore, this client should be
experiencing improvement in depressive manifestations and be ready to interact in a group
setting.
B. The nurse should not recommend this client for group therapy until the psychosis resolves.

C. The nurse should not plan to include this client in group therapy until the client can interact
appropriately with others.
D. The nurse should not plan to include this client in group therapy until the intoxication
resolves.
23. A nurse is planning care for a client newly admitted with major depressive disorder. Which of
the following actions should the nurse plan to take?
A. Ask the client to create her own schedule of daily activities.
B. Teach the client to use passive communication when interacting with others.
C. Determine the client’s need for assistance with grooming.
D. Limit the client’s involvement in unit activities.
Answer: C. Determine the client’s need for assistance with grooming.
Rationale:
A. The nurse should expect a client who has major depressive disorder to have difficulty making
decisions.
B. The nurse should encourage the client to use assertiveness techniques to increase self-esteem.
C. The nurse should promote problem-solving by helping the client identify situations which can
or cannot be controlled. This can help the client deal with unresolved issues.
D. The nurse should recognize the client will want to spend most of her time alone; the nurse
should encourage interaction with groups to increase her self-esteem.
24. A nurse at a college campus mental health counseling center is caring for a student who just
failed an examination. The student spends the session berating the teacher and the course. The
nurse should recognize this behavior as which of the following defense mechanisms?
A. Conversion
B. Projection
C. Undoing
D. Regression
Answer: B. Projection
Rationale:

A. The nurse should identify conversion as a defense mechanism in which the client
unconsciously expresses emotional conflict via physical symptoms, such as paralysis or loss of
sensory function.
B. Projection is a defense mechanism in which the client refuses to acknowledge unacceptable
personal characteristics and transfers feelings, thoughts, or traits onto another person. Instead of
dealing with his own failures, the client is describing the shortcomings of the course and teacher.
C. The nurse should identify undoing as a defense mechanism in which the client takes an action
to make up for a wrong action or statement.
D. The nurse should identify regression as a defense mechanism in which the client adopts a
more primitive, immature behavior in response to an unwanted situation.
25. A nurse in a drug and alcohol detoxification center is planning care for a client who has
alcohol use disorder. Which of the following interventions should the nurse identify as the
priority?
A. Helping the client identify positive personality traits
B. Providing for adequate hydration and rest
C. Confronting the use of denial and other defense mechanisms
D. Educating the client about the consequences of alcohol misuse
Answer: B. Providing for adequate hydration and rest
Rationale:
A. Assessment of coping skills is important, but it is not the primary focus of care during the
early phase of alcohol withdrawal.
B. Providing for the client's physical needs should be the nurse's priority until the client
completes the detoxification phase of treatment. Rest is important for two reasons: alcohol use
disrupts normal sleep patterns, and alcohol withdrawal or detoxification is often associated with
increased restlessness and agitation. Restoring and maintaining fluid and electrolyte balance is
another important goal during detoxification to prevent fluid and electrolyte imbalances.
C. The nurse should help the client admit a problem, but this is not the primary focus of care
during the early phase of alcohol withdrawal.
D. The nurse should help the client understand consequences, but this is not the primary focus of
care during the early phase of alcohol withdrawal.

26. A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client
says he is bored. Which of the following activities is appropriate for the nurse to suggest to this
client?
A. Watching a video with a group in the day room
B. Walking with the nurse in the courtyard
C. Participating in a basketball game in the gym
D. Joining a group discussion about a local election
Answer: B. Walking with the nurse in the courtyard
Rationale:
A. The nurse should limit the client’s exposure to groups and crowds because it can increase the
client’s hyperactivity.
B. Clients who have bipolar disorder are prone to hyperactivity. The nurse should provide
activities that provide a way for the client to release physical energy, while avoiding situations
that might provoke the client. In addition, walking with the nurse provides an opportunity for
therapeutic communication.
C. The nurse should not encourage the client to participate in competitive games because it can
increase the client’s hyperactivity.
D. The nurse should limit the client’s exposure to groups and crowds because it can increase the
client’s hyperactivity.
27. A nurse in a hospital is caring for a client who has agoraphobia. Which of the following
statements by the client indicates understanding of the goals of treatment?
A. "I plan to sit on a park bench for a few minutes each day."
B. "I can try participating in group therapy every week."
C. "I will join a book club in my neighborhood."
D. "I should avoid entering elevators and other closed spaces."
Answer: A. "I plan to sit on a park bench for a few minutes each day."
Rationale:

A. Agoraphobia is fear of being in places in which help may not be available. This typically
manifests as a fear of being outside alone. Therefore, the nurse should identify this statement as
understanding of the goals of treatment.
B. The client's phobia does not concern exposure to other people.
C. The client's phobia does not concern exposure to other people.
D. The client's phobia does not concern exposure to other people.
28. A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which
of the following actions should the nurse identify as the priority?
A. Lock the doors to the unit and secure windows so they cannot be opened.
B. Provide the client with plastic eating utensils for meals.
C. Remove any objects from the client’s environment that could be used for self-harm.
D. Assign a staff member to stay with the client at all times.
Answer: D. Assign a staff member to stay with the client at all times.
Rationale:
A. The nurses should lock the doors and windows on the unit so the client cannot leave the unit,
or obtain objects for inflicting self-harm; however, the nurse should identify another action as the
priority.
B. The nurse should provide the client with plastic eating utensils to avoid providing the client
with an object for inflicting self-harm; however, the nurse should identify another action as the
priority.
C. The nurse should remove objects from the environment that could be used for self-harm.
Additionally, the nurses should check the client’s belongings, and prevent visitors from brining
in harmful objects; however, the nurse should identify another action as the priority.
D. The greatest risk to this client is self-injury during unsupervised time; therefore, the nurse
should identify the priority action is to assign a staff member to stay with the client at all times.
The staff member can monitor all of the client’s behaviors and actions and prevent the client
from harming herself.
29. A nurse in an emergency department is assessing a client for suspected cocaine intoxication.
Which of the following findings should the nurse expect?

A. Nystagmus
B. Dilated pupils
C. Hypersomnia
D. Depression
Answer: B. Dilated pupils
Rationale:
A. Nystagmus, a rapid involuntary oscillation of the eyeballs, is not associated with cocaine
intoxication. The client can experience perspiration and tremors.
B. dilated pupils are a finding of cocaine intoxication due to the stimulation of the sympathetic
nervous system.
C. The nurse should expect the client to exhibit hypervigilance and have increased energy.
D. The nurse should expect the client to exhibit euphoria and grandiosity.
30. A nurse is caring for a client who is extremely suspicious of the nursing staff and other
clients. Which of the following nursing approaches is appropriate when establishing a therapeutic
relationship with this client?
A. Disclose some personal information to the client to demonstrate approachability.
B. Wait for the client to initiate interaction.
C. Approach the client frequently throughout the day for brief interactions.
D. Adopt a neutral attitude when providing care.
Answer: D. Adopt a neutral attitude when providing care.
Rationale:
A. The nurse should provide the client with general leads and maintain the boundaries of a
professional therapeutic relationship with the client rather than a social relationship.
B. The nurse should initiate interaction with the client to show interest in the client’s needs and
to establish rapport.
C. The nurse should avoid appearing too friendly, but should use a straightforward attitude
during care and communication.
D. To promote a therapeutic relationship, the nurse should use a neutral, nonthreatening attitude
during care and communication.

31. A nurse at a walk-in mental health clinic is assessing a client experiencing severe anxiety.
The nurse should recognize the client might exhibit which of the following manifestations?
A. Attention-seeking conduct
B. Mild difficulty problem solving
C. Mild fidgeting
D. Threatening behavior
Answer: D. Threatening behavior
Rationale:
A. The nurse should expect a client experiencing severe anxiety to exhibit purposeless behavior.
B. The nurse should expect a client experiencing severe anxiety to report that problem solving
seems impossible.
C. When experiencing severe anxiety, the client's perceptual field is scattered and the client is not
able to focus on anything except relieving the anxiety.
D. The client experiencing severe anxiety can have feelings of confusion and impending doom.
The client may feel the need to be aggressive and defensive, speaking with loud, rapid speech
and possibly making threats and demands of others.
32. A nurse observes that a client who has depression is sitting alone in the room crying. As the
nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right
now." Which of the following responses should the nurse make?
A. "It might help you feel better if you talk about it."
B. "I'll just sit here with you for a few minutes then."
C. "I understand. I've felt like that before, too."
D. "Why are you feeling so down?"
Answer: B. "I'll just sit here with you for a few minutes then."
Rationale:
A. This response by the nurse provides false reassurance, and is therefore nontherapeutic.
B. This therapeutic response is an example of offering self. By sitting with the client, the nurse
demonstrates caring and concern, and shows the client that the nurse is available if the client
wants to talk.

C. This response by the nurse shows approval or agreement. It is nontherapeutic response
because it implies that not communicating is the right thing to do, and could cause the client to
focus on the approval of the staff instead of making her own choices.
D. This response includes a “why” statement, which could cause the client to feel defensive.
Therefore, this statement is nontherapeutic.
33. A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining
weight. Which of the following nursing actions should the nurse take?
A. Praise the client for looking at herself in a mirror.
B. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise.
C. Reprimand the client about the potential damage that has occurred due to overexercising her
body.
D. Restrict the client from being weighed.
Answer: B. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise.
Rationale:
A. A client who has anorexia nervosa monitors weight and appearance excessively, but does not
have a proper body image. The nurse should avoid sounding too complimentary of the client’s
appearance because it may reinforce negative thoughts.
B. To promote effectiveness of treatment, the nurse should implement actions which establish
trust and partnership with the client. This action should help the client view the nurse as a partner
in treatment.
C. The nurse should focus teaching on healthy eating and addressing wrong thoughts about
weight gain. Confronting the client is not likely to be effective until the client can resolve the
issues that underlie the behaviors associated with anorexia nervosa.
D. During therapy, the nurse should weigh the client daily for the first week, then three times a
week. A client who has anorexia nervosa is likely to want to avoid weighing or seeing the
weight.
34. A nurse is caring for a client who has a history of alcohol use disorder and has been
hospitalized for detoxification. The nurse enters the room and finds the client shouting in a

terrified voice, "Get these bugs off of me!" Which of the following responses by the nurse is
appropriate?
A. "I'm sure that the bugs you see will not harm you."
B. "Tell me more about the bugs that you see in your room."
C. "I don't see any bugs, but you seem very frightened."
D. "I do not see anything. This is part of the withdrawal process."
Answer: C. "I don't see any bugs, but you seem very frightened.
Rationale:
A. The nurse should avoid talking about the hallucinations as though they are true.
B. The nurse should avoid talking about the hallucinations as though they are true.
C. This client is experiencing a tactile hallucination, which is common during alcohol
withdrawal. This response by the nurse presents reality and shows empathy by acknowledging
the client's feelings.
D. The nurse should not argue with what the client is experiencing, as the hallucinations are very
real to the client.
35. A nurse is conducting a group therapy session for several clients. The group is laughing at a
joke one of the clients told, when a client who is schizophrenic jumps up and runs out of the
room yelling, "You are all making fun of me!" The nurse should identify this behavior as which
of the following characteristics of schizophrenia?
A. Magical thinking
B. Delusions of grandeur
C. Ideas of reference
D. Looseness of association
Answer: C. Ideas of reference
Rationale:
A. The nurse should recognize that magical thinking occurs when a client believes his actions or
thoughts can magically make things happen.
B. The nurse should recognize that delusions of grandeur occur when a client attaches special
significance to his self-stature and has a drastically exaggerated sense of self-importance.

C. When ideas of reference are present, the client believes all events, situations, or interactions
are directly related to him.
D. The nurse should recognize associate looseness occurs when the client’s verbal
communication jumps from one unrelated topic to another. The client is often unaware he is not
making sense.
36. A community health nurse is providing teaching to the family of a client who has primary
dementia. Which of the following manifestations should the nurse tell the family to expect?
A. Decreased auditory and visual acuity
B. Decreased display of emotions
C. Personality traits that are opposite of original traits
D. Forgetfulness gradually progressing to disorientation
Answer: D. Forgetfulness gradually progressing to disorientation
Rationale:
A. Dementia is not known to affect auditory and visual senses. The nurse should instruct the
family to expect the client’s reasoning and logic skills to decline.
B. The nurse should tell the family to expect the client to be unable to control emotions and
behavior, and be more likely to exhibit emotional outbursts.
C. The nurse should instruct the family to expect the client to demonstrate an exaggeration of
previous personality traits.
D. Dementia usually appears first as forgetfulness. Other manifestations may be apparent only
upon neurologic examination or cognitive testing. Loss of functioning progresses slowly from
impaired language skills and difficulty with ordinary daily activities to severe memory loss and
complete disorientation with withdrawal from social interaction.
37. A male nurse is assigned to care for a female client who was admitted to the hospital for
treatment of injuries following a domestic abuse incident. The client tells the nurse manager she
does not want a male nurse as her caregiver. Which of the following nursing responses should the
nurse manager make?
A. "I can arrange for a female assistive personnel to do your personal hygiene care."

B. "The nurse assigned to care for you is very capable and cares for other women in this
situation."
C. "Your doctor is a man, so it seems like this should not be a problem."
D. "I can review the assignments and arrange for a female nurse to care for you."
Answer: D. "I can review the assignments and arrange for a female nurse to care for you."
Rationale:
A. This is not a therapeutic response to the client's needs. It does not address the client’s fear of
being cared for by a male.
B. In this nontherapeutic response, the nurse blocks further communication with the client by
being defensive.
C. In this nontherapeutic response, the nurse blocks further communication by ignoring the
client’s concerns.
D. In this therapeutic response, the nurse demonstrates empathy by endeavoring to meet the
client's request for a female caregiver.
38. A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should
know that the client can be kept in the hospital after the 72-hr hold is over for which of the
following conditions?
A. The client is a danger to herself or others.
B. The client is unwilling to accept that treatment is needed.
C. The client states that she does not like the neighbor.
D. The client states that she plans to move out of the state immediately.
Answer: A. The client is a danger to herself or others.
Rationale:
A. The criteria for involuntary admission includes that the client has a mental disorder that will
likely result in serious bodily harm to self or another person, unless the client remains in a
psychiatric facility.
B. This is not sufficient grounds for detaining the client once the involuntary hold has expired.
C. This is not sufficient grounds for detaining the client once the involuntary hold has expired.
D. This is not sufficient grounds for detaining the client once the involuntary hold has expired

39. A nurse is caring for a client who has bipolar disorder and a new prescription for valproate.
Which of the following instructions should the nurse give the client about the use of this
medication?
A. Thyroid function tests should be performed every 6 months.
B. A pretreatment electroencephalogram (EEG) will be done.
C. Liver function tests must be monitored.
D. High serum sodium levels can cause toxic levels of valproate.
Answer: C. Liver function tests must be monitored.
Rationale:
A. Hypothyroidism is a long-term risk for clients who take lithium, not valproate.
B. An EEG is a test that examines brain waves and is used for clients who have a seizure
disorder. Although valproate is used as an anticonvulsant in some clients, an EEG is not
necessary because this client is using valproate as a mood stabilizer for bipolar disorder, not as
an anticonvulsant.
C. Pancreatitis, hepatic dysfunction, and thrombocytopenia are serious adverse effects
occasionally associated with valproate. Liver function tests should be monitored periodically to
check for hepatic failure.
D. Low serum sodium levels affect lithium levels, but serum sodium does not affect blood levels
of valproate.
40. A nurse in an acute care mental health facility is preparing to administer morning medication
for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0
mEq/L. Which of the following actions should the nurse take?
A. Prepare for gastric lavage due to an extremely elevated lithium level.
B. Administer the morning dose of lithium.
C. Check the client's medication record to assess whether the client has been refusing her
lithium.
D. Hold the medication and assess for early manifestations of toxicity.
Answer: B. Administer the morning dose of lithium.
Rationale:

A. Based on the client's current lithium level, preparing for gastric lavage is not the correct
nursing action.
B. The nurse should administer the lithium dose since a lithium level of 1.0 mEq/L is within the
expected initial therapeutic range of 0.8 to 1.3 mEq/L. At a therapeutic level the client might
demonstrate adverse effects of lithium, such as a fine hand tremor, thirst, and mild nausea, and
the nurse should note if any of these manifestations are present. The nurse should continue to
monitor for adverse effects and signs of toxicity, which usually occur at levels of 1.5 mEq/L or
higher.
C. Based on the client's current lithium level, checking the medication record to assess whether
the client has been refusing lithium is not the correct nursing action.
D. Based on the client's current lithium level, holding the medication and assessing for early
manifestations of toxicity is not the correct action.
41. A nurse observes a client's spouse sitting alone in the waiting room crying. When
approached, the spouse says, "I am really concerned about my husband." Which of the following
is a therapeutic nursing response?
A. "Your husband is making really good progress."
B. "Crying helps us let things out and we feel better.”
C. "Did your husband say something to upset you?"
D. "Tell me what is concerning you."
Answer: D. "Tell me what is concerning you."
Rationale:
A. This nontherapeutic response uses the communication block of focusing on an inappropriate
person (the spouse). It negates the spouse’s concerns.
B. This non-therapeutic response makes a statement about what the nurse believes, but does not
encourage communication about the spouse’s concerns.
C. This nontherapeutic response uses the communication block of focusing on an inappropriate
person and is a closed-end question.
D. This therapeutic response uses the communication tool of clarification. This response
encourages further communication and expression of feelings.

42. A nurse is caring for a client who is depressed and refuses to participate in group therapy or
perform activities of daily living. Which of the following statements should the nurse make to
the client?
A. "I will assist you in getting out of bed and getting dressed."
B. "You can remain in bed until you feel well enough to join the group."
C. "The unit rules state that you may not remain in bed."
D. "If you don't participate in your care, you will not get better."
Answer: A. "I will assist you in getting out of bed and getting dressed."
Rationale:
A. Severely depressed persons have problems with self-care and are easily overwhelmed. A
nursing approach that focuses on meeting the client's physiologic and basic needs directly is best.
The presence of the nurse conveys that the client is worthy of the nurse's attention and will help
the client adjust to the hospitalization.
B. This nontherapeutic approach uses the communication block of ignoring the client's basic
needs.
C. This nontherapeutic approach uses the communication block of focusing on the rules instead
of the client.
D. This nontherapeutic approach uses the communication block of threatening the client.
43. A nurse is caring for a client who has borderline personality disorder (BPD). As part of the
client's plan of care, the nurse reviews the day's schedule with the client each morning. As the
nurse begins to review the schedule with the client, the client says, "Why don't you shut up
already? I can read it myself, you know!" Which of the following responses should the nurse
give the client?
A. "We do this every day. Why are you so angry with me this morning?"
B. "I don't like it when you address me with that tone of voice."
C. "I know you can, but are you going to read it or not?"
D. "Fine. Here is the schedule, and I will expect you to be on time to your therapies."
Answer: B. "I don't like it when you address me with that tone of voice."
Rationale:

A. This nontherapeutic response is defensive and also expects an anxious client to answer an
introspective question. Asking a client "why" is rarely a correct response. More importantly, it
does not call to the client's attention the inappropriate behavior and set appropriate limits for
further communication.
B. BPD is described as an emotionally unstable personality. Clients who have BPD might show a
wide range of impulsive behaviors in all aspects of their lives, including self-destructive
behaviors. The client in this situation has overstepped a limit by addressing the nurse in a lessthan-respectful tone of voice. This therapeutic response calls to the client's attention the
inappropriate behavior and sets appropriate limits for further communication. This is the best
approach to continue communication with this client.
C. This nontherapeutic response is a closed-ended question that challenges the client. More
importantly, it does not call to the client's attention the inappropriate behavior and set appropriate
limits for further communication.
D. This nontherapeutic response is a closed-ended statement that challenges the client. More
importantly, it does not call to the client's attention the inappropriate behavior and set appropriate
limits for further communication.
44. A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder
(OCD) and is constantly picking up after others in the day room. The nurse should recognize that
the client uses this behavior to do which of the following?
A. Limit the amount of time available to interact with others.
B. Focus attention on meaningful tasks.
C. Manipulate and control others' behaviors.
D. Decrease anxiety to a tolerable level.
Answer: D. Decrease anxiety to a tolerable level.
Rationale:
A. This is not the etiology of OCD behaviors.
B. The repetitive rituals most commonly involve meaningless tasks.
C. Clients whose behavior pattern seeks to control or manipulate others are clients with
personality disorders such as borderline, antisocial, histrionic, or passive-aggressive personality
disorders.

D. With OCD, obsessions give rise to anxiety, and the anxiety is then reduced by compulsive
behaviors. Compulsive rituals are strengthened and maintained because they decrease the anxiety
by terminating the event that gives rise to it.
45. A nurse is assessing a parent who lost a 12-year-old child in a car crash 2 years ago. Which of
the following findings indicates the client is exhibiting manifestations of prolonged grieving?
A. Leaves the child's room exactly as it was before the loss
B. Volunteers at a local children's hospital
C. Talks about the child in the past tense
D. Visits the child's grave every week after worship services
Answer: A. Leaves the child's room exactly as it was before the loss
Rationale:
A. Grieving becomes dysfunctional when the client is unable to resume regular activities of daily
living or experience emotions other than sadness or depression. An example of dysfunctional
grieving is making the loved one's room a shrine for more than a year.
B. The ability to resume normal activities of daily living is an important step in the resolution of
the grieving process. Volunteering at a children's hospital shows that the client is resuming
normal activities of daily living and is able to give to others.
C. Talking about the child in the past tense is considered an appropriate act of eulogizing the
child.
D. Visiting the child's grave weekly is considered an appropriate remembrance of the child.
46. A nurse on a crisis hotline is speaking to a client who says, "I just took an entire bottle of
amitriptyline." Which of the following responses should the nurse make?
A. "I'm glad you called, and I want to send an ambulance to help you."
B. "You must have been feeling pretty depressed to do that."
C. "Do you know how many pills were in the bottle?"
D. "Were you trying to kill yourself by taking an overdose?"
Answer: A. "I'm glad you called, and I want to send an ambulance to help you."
Rationale:

A. Amitriptyline, a tricyclic antidepressant, is used to treat depression. This therapeutic statement
shows the nurse's concern for the client's safety and responds to the client's priority need.
Maslow's hierarchy of needs states that the client's physical and safety needs come first.
Therefore, the client needs to be evaluated immediately.
B. This client is in immediate danger. Therefore, this is a nontherapeutic statement and is not
appropriate for the nurse to state.
C. This client is in immediate danger. Therefore, this is a nontherapeutic statement and is not
appropriate for the nurse to state.
D. This client is in immediate danger. Therefore, this is a nontherapeutic statement and is not
appropriate for the nurse to state.
47. A nurse is caring for a client who has major depressive disorder and is scheduled for
electroconvulsive therapy (ECT). The client's spouse asks the nurse about the possible side
effects of the ECT. Which of the following responses should the nurse make?
A. "The main side effects are temporary, and may include mild confusion, a headache, and shortterm memory loss."
B. "Most clients have no adverse effects to this treatment, but muscle cramping may result from
the induced seizure."
C. "Some clients have been known to have a myocardial infarction, but we will monitor your
spouse closely to be certain this does not happen."
D. "The most common side effects are directly related to the use of anesthesia."
Answer: A. "The main side effects are temporary, and may include mild confusion, a headache,
and short-term memory loss."
Rationale:
A. The main side effects are mild disorientation and confusion immediately after the treatment, a
slight headache, and short-term memory problems.
B. Muscle cramping is not a side effect of ECT. Before receiving the treatment, the client is
medicated with a muscle relaxant to prevent any muscle contractions during the brain seizure.
C. Myocardial infarction is not an expected side effect of ECT therapy.
D. There are other temporary adverse effects associated with the ECT itself.

48. A nurse is caring for a group of clients. The nurse should recognize that which of the
following clients is at risk for a vitamin B6 deficiency?
A. A client who takes gabapentin as part of treatment phenytoin for a seizure disorder.
B. A client who has asthma.
C. A client who has chronic alcohol use disorder.
D. A client who takes heparin to prevent deep vein thrombosis.
Answer: C. A client who has chronic alcohol use disorder.
Rationale:
A. Neither epilepsy nor oral anticonvulsant therapy increases a client's risk for B6 deficiency.
The nurse should recognize gabapentin could cause increased appetite and weight gain.
B. The nurses should not expect a client who has asthma to be at risk for vitamin deficiencies.
C. The nurse should recognize that alcohol consumption destroys and increases elimination of
vitamin B6 from the body; therefore, this client is at risk for vitamin B6 deficiency.
D. The nurse should recognize heparin does not cause a vitamin B6 deficiency, but can cause
thrombocytopenia.
49. A nurse is caring for an adolescent who is experiencing indications of depression. Which of
the following findings should the nurse expect? (Select all that apply.)
A. irritability
B. Euphoria
C. Insomnia
D. Low self-esteem
E. Chronic pain
Answer: A. irritability
C. Insomnia
D. Low self-esteem
E. Chronic pain
Rationale:
A. Depressed teens are often irritable, taking out much of their anger on their friends and family.
Signs include being critical, sarcastic, or abusive, and appearing restless, agitated, and angry.

B. Euphoria, or a feeling of well-being or elation, is not associated with depression; it is
associated with the manic phase of bipolar disorder.
C. Insomnia (too little sleep) and hypersomnia (too much sleep) are two sleep pattern
disturbances that may be associated with depression. A depressed teen may also complain of
chronic or persistent fatigue, regardless of the amount of sleep they get.
D. Low self-esteem is one of the most common causes of teen depression. Teens who have
trouble in school are at a higher risk for depression than kids who do well in school. Somatic, or
physical, symptoms of depression are common in teens.
E. Chronic pain that is not caused by physical disease most often includes headaches and
stomach aches.
50. A nurse is caring for a hospitalized client who tells lies about other clients. The other clients
on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which
of the following initial actions should the nurse take?
A. Talk to the client and identify the specific limits that are required of the client's behavior.
B. Discuss the problem in a community meeting with the other clients on the unit present.
C. Escort the client to her room each time the nurse observes the client socializing with other
clients.
D. Tell the other clients to ignore the client's lies.
Answer: A. Talk to the client and identify the specific limits that are required of the client's
behavior.
Rationale:
A. Discussing the problem behaviors with the client and informing her of which behaviors
cannot be done on the unit is therapeutic communication.
B. This is not appropriate, as. there is no need for other clients on the unit to be involved.
C. Preventing the client from interacting with others on the unit will isolate the client and tend to
encourage further inappropriate behaviors.
D. Telling the other clients to ignore the behavior does nothing to solve the problem and does not
help their feelings of the other clients.

51. A nurse is caring for several clients who have mental health disorders at an assisted-living
facility. Which of the following clients should the nurse determine needs to be seen by a provider
immediately?
A. A client who is taking olanzapine and experiences dizziness when first standing up
B. A client who is taking chlorpromazine and reports vomiting twice
C. A client who is taking thioridazine and has daytime drowsiness
D. A client who is taking clozapine, and has flu-like manifestations
Answer: D. A client who is taking clozapine, and has flu-like manifestations
Rationale:
A. This client is at risk for falls because olanzapine can cause orthostatic hypotension; however,
there is another client the nurse should identify as the priority.
B. This client is at risk for dehydration if vomiting continues and could require an antiemetic;
however there is another client the nurses should identify as the priority.
C. This client is at risk for falls because thioridazine-induced drowsiness may affect
coordination; however, there is another client the nurse should identify as the priority.
D. Clozapine is used to treat schizophrenia and can cause life-threatening agranulocytosis.
Presence of flu-like manifestations indicates that this is the client at greatest risk; therefore, the
nurse should contact this client’s provider immediately.
52. A nurse is caring for a client who is hospitalized for the treatment of severe depression.
Which of the following nursing approaches is therapeutic to include in the client's plan of care?
A. Encouraging decision-making
B. Giving the client choices of activities
C. Playing a game of chess with the client
D. Spending time sitting with the client
Answer: D. Spending time sitting with the client
Rationale:
A. This is not an appropriate nursing approach to include in this client's plan of care. Decisionmaking is difficult for a client who has depression.
B. This is not an appropriate nursing approach to include in this client's plan of care. Making
choices is difficult for a client who has depression.

C. This is not a therapeutic approach for this client. An intellectual game that requires making
choices and decisions, such as chess, would not be a good activity for a client who has
depression. Participating in non-intellectual pursuits, such as crafts or similar activities in the day
room, would be a better choice.
D. This option uses the therapeutic communication tool of being silent. Because clients who have
depression frequently have suicidal tendencies, spending time with the client will provide for
safety. Depression also involves diminished self-esteem, and spending time with the client
conveys that the client is worth the nurse's time and attention.
53. A nurse is caring for a client who was admitted to the facility in critical condition following a
cerebrovascular accident. The client's son says to the nurse, "I wish I could stay, but I need to go
home to see how my children are doing. I really hate to leave." Which of the following responses
should the nurse make?
A. "Perhaps you could call your children to see how they are doing."
B. "Don't worry. We'll take good care of your parent while you are gone."
C. "You are feeling drawn in two separate directions."
D. "There's nothing you can do here. You should go home to your children."
Answer: C. "You are feeling drawn in two separate directions."
Rationale:
A. This response illustrates the nontherapeutic communication block of giving advice rather than
the therapeutic response of focusing on the son's feelings.
B. This response illustrates the nontherapeutic communication blocks of devaluing feelings and
using a cliché, rather than the therapeutic response of focusing on the son's feelings.
C. This response illustrates the therapeutic communication technique of restatement. This openended statement encourages further communication by the son.
D. This response illustrates the nontherapeutic communication block of giving advice rather than
the therapeutic response of focusing on the son's feelings.
54. A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for
treatment of pneumonia. During the night shift, the client is found climbing into the bed of

another client who becomes upset and frightened. Which of the following actions should the
nurse take?
A. Assist the client to the correct room.
B. Place the client in restraints.
C. Reorient the client to time and place.
D. Move the client to a room at the end of the hall.
Answer: A. Assist the client to the correct room.
Rationale:
A. Assisting the client to the correct room protects both clients. It helps reorient the client who is
unable to find her own room, and it protects the other client from an invasion of her personal
space.
B. Restraining a client in situations other than for the client's physical safety is unethical and
illegal. This action by the nurse is not appropriate.
C. This action does not address that the client went into another client's room.
D. The client should be placed in a room that can be monitored easily. Furthermore, moving the
client to another room might increase the client's disorientation.
55. A nurse is reviewing medication records for several clients who have bipolar disorder. The
nurse should recognize that which of the following medications are used to treat clients who
have bipolar disorder? (Select all that apply.)
A. Paroxetine
B. Lithium
C. Donepezil
D. Valproate
E. Carbamazepine
Answer: A. Paroxetine
B. Lithium
D. Valproate
E. Carbamazepine
Rationale:

A. Paroxetine is correct. Paxil is an antidepressant in a class of medications called selective
serotonin reuptake inhibitors (SSRIs). SSRIs are used to treat depressive episodes associated
with bipolar disorder.
B. Lithium is correct. Lithium is a salt that acts on the central nervous system and is used to treat
the manic stage of bipolar disorder. It may also reduce the frequency and severity of depression
in bipolar disorder.
C. Donepezil is incorrect. Donepezil is a cholinesterase inhibitor used to improve cognition in
clients who have Alzheimer's disease.
D. Valproate is correct. Valproate is an anticonvulsant medication which is also effective as a
mood stabilizer for clients who have bipolar disorder.
E. Carbamazepine is correct. Carbamazepine is an anticonvulsant medication which is also
effective as a mood stabilizer for clients who have bipolar disorder.
56. A nurse is caring for a client who is hospitalized and says to the nurse, "My partner called
and told me my boss hired someone to take my place." Which of the following responses should
the nurse make?
A. "You should call your boss and ask if you can have your job back."
B. "I don't understand why your partner would upset you with news like that."
C. "There really isn't much you can do about that until you are discharged."
D. "You must feel very concerned and disappointed by that information."
Answer: D. "You must feel very concerned and disappointed by that information."
Rationale:
A. This is a nontherapeutic response and does not address the client's feelings.
B. This is a nontherapeutic response that focuses on the client's partner. It does not address the
client's feelings.
C. This is a nontherapeutic response and does not address the client's feelings.
D. This is a therapeutic response and an open-ended empathetic statement that encourages the
client to talk.

57. A nurse is caring for a client who has major depressive disorder and attempted suicide. The
client tells the nurse, "I should have died because I am totally worthless." Which of the following
responses should the nurse make?
A. "You have a great deal to live for."
B. "It's not unusual for depressed people to feel that way."
C. "Why do you feel you are worthless?"
D. "You've been feeling that your life has no meaning."
Answer: D. "You've been feeling that your life has no meaning."
Rationale:
A. In this nontherapeutic response the nurse is using a cliché. The nurse is telling the client that
there is a lot to live for when, in fact, he doesn't know the client's current situation. A statement
like this will lead the client to think that the feeling of worthlessness is wrong and disapproved
of, making the client less likely to disclose further personal feelings to the nurse.
B. This nontherapeutic response is a generalization and does not address the client's feelings or
the client as an individual.
C. This nontherapeutic response requires the client to answer a "why" question that the client
may be unable to answer. The nurse should avoid asking clients "why" questions, especially
depressed or suicidal clients who may not have the ability to articulate a reply.
D. This open-ended statement uses the communication tool of empathy and addresses the client's
feeling of worthlessness. This therapeutic response communicates to the client that the nurse was
listening, and it will encourage the client to talk further about personal feelings.
58. A charge nurse is admitting a client who has bipolar disorder and who is in the manic phase.
Which of the following room assignments should the nurse give the client?
A. A semi-private room across from the day room.
B. A private room across from the nurse’s station.
C. A private room across from the exercise room.
D. A semi-private room across from the snack area.
Answer: B. A private room across from the nurse’s station.
Rationale:

A. The nurse should not place a client in the manic phase near the day room because of the high
level of activity in that area. Also, placing the client with a roommate would subject the
roommate to his overactive behavior, which could worsen due to overstimulation.
B. A private room decreases stimuli for the client and does not subject another client to his
overactive behavior.
C. The nurse should not place the client near the exercise room because of the high level of
activity in that area, and the client might exhaust himself exercising.
D. The nurse should not place the client with a roommate because it would subject the roommate
to his overactive behavior, which could worsen due to overstimulation.
59. A nurse is planning a unit orientation for a newly admitted client who has severe depression.
Which of the following should be the nurse's approach?
A. Sit with the client and offer simple, direct information.
B. Have the client attend group therapy immediately.
C. Explain the unit policies to the client and answer any questions he might have.
D. Take the client on a tour of the unit and introduce him to all the staff members on duty.
Answer: A. Sit with the client and offer simple, direct information.
Rationale:
A. Severely depressed clients can have problems with concentration and are easily overwhelmed.
A nursing approach that focuses on giving simple information slowly and directly is best for the
newly admitted client.
B. Clients who are severely depressed are often uncommunicative and socially withdrawn;
therefore, this approach might be overwhelming and counter-productive for the newly admitted
client.
C. Clients who are severely depressed often have poor concentration and the inability to take
action; therefore, this approach might be overwhelming for the newly admitted client.
D. Clients who are severely depressed are often uncommunicative and withdrawn; therefore, this
approach might be overwhelming for the newly admitted client.

60. A nurse is making a home visit to a client who has Alzheimer's disease and the client's
partner. Which of the following observations indicates to the nurse that the partner is
experiencing caregiver role strain?
A. The partner has placed locks at the top of the doors leading to the outside.
B. The partner has hired a house cleaner.
C. The partner has lost 20 lb in the past 2 months.
D. The partner redirects the client when the client is frustrated.
Answer: C. The partner has lost 20 lb in the past 2 months.
Rationale:
A. Placing locks at the top of the doors is a way to prevent the client who has Alzheimer's from
wandering off. This observation is not an indication of caregiver role strain.
B. Hiring a house cleaner indicates the partner is seeking assistance in his role as caregiver. This
observation is not an indication of caregiver role strain.
C. A large weight loss by the caregiver is an indication of caregiver role strain.
D. Using distraction to manage the behavior of a client who has Alzheimer's is a positive
intervention. This observation is not an indication of caregiver role strain.
61. A nurse is caring for a client who is cognitively impaired. Which of the following rooms will
provide a therapeutic environment for this client?
A. A room adjacent to the nursing station
B. A room without a window
C. A room with dim lighting
D. A room containing personal belongings
Answer: D. A room containing personal belongings
Rationale:
A. Clients who have impaired cognition need a low-stimulation environment. A room adjacent to
the nursing station might provide too much stimulation for this client.
B. Clients who have impaired cognition are often disoriented and cannot distinguish between
night and day. A room without a window may contribute to the disorientation.
C. Clients who have impaired cognition are often disoriented. A room with dim lighting might
not maximize environmental clues for the client.

D. A room that contains several of the client's personal belongings assists in maintaining personal
identity and provides a therapeutic environment.
62. A nurse is caring for an adolescent female who has an eating disorder. The client is 162.6 cm
(64 in) tall and weighs 38.56 kg (85 lb). Upon assessment, which of the following manifestations
should the nurse expect? (Select all that apply.)
A. Amenorrhea
B. Verbalized desire to gain weight
C. Altered body image
D. Hyperactivity
E. Bradycardia
Answer: A. Amenorrhea
C. Altered body image
D. Hyperactivity
E. Bradycardia
Rationale:
A. Amenorrhea is correct. A client who has anorexia nervosa and has had significant weight loss
will commonly experience amenorrhea, or cessation of menses.
B. Verbalized desire to gain weight is incorrect. A client who has anorexia nervosa sees herself as
overweight and often has fear of gaining weight.
C. Altered body image is correct. A client who has anorexia nervosa will commonly view her
body as overweight no matter how much weight is lost.
D. Hyperactivity is correct. A client who has anorexia nervosa will commonly engage in
excessive exercising to prevent weight gain.
E. Bradycardia is correct. A client who has anorexia nervosa can experience cardiac
abnormalities, such as bradycardia and hypotension.
63. A nurse is caring for an adolescent who has a history of violent behavior and has asked the
nurse to keep confidential information about the desire to kill several classmates and a school
teacher. Which of the following responses by the nurse is appropriate to give?

A. "Because you are a minor, I have to share any information that I feel is important with your
parents."
B. "I cannot promise that. I must share this information with other members of the team who are
responsible for planning your care."
C. "I will not violate our nurse-client relationship. The information we discuss will remain
confidential between us."
D. "I can see that you trust me, but you should share those feelings with your psychiatrist, not
me."
Answer: B. "I cannot promise that. I must share this information with other members of the team
who are responsible for planning your care."
Rationale:
A. The nurse must follow guidelines for reporting information to the parents of a minor client.
B. The nurse should report issues that are potentially life-threatening to the treatment team.
Although trust is the hallmark of the nurse-client relationship, confidentiality does not extend to
these situations.
C. The nurse should not promise to keep all client information confidential, because certain
situations require the nurse to disclose information.
D. This response by the nurse is nontherapeutic because it shifts the responsibility for this
information back to the client.
64. A nurse is preparing to teach a client about his prescription of lithium for the treatment of
bipolar disorder. Which of the following statements should the nurse include in the teaching?
A. "You will need to consume a low-salt diet while on this medication."
B. "You will need your blood levels drawn weekly during the first month."
C. "You will need to take this medication on an empty stomach."
D. "You will need to stop this medication if you experience diarrhea."
Answer: D. "You will need to stop this medication if you experience diarrhea."
Rationale:
A. The nurse should recommend a diet with adequate amounts of salt and fluid.
B. The nurse should inform the client to have serum lithium levels measured at least two times a
week until the level stabilizes, and then every 2 months.

C. The nurse should recommend the client take lithium with food or milk to prevent
gastrointestinal irritation.
D. Diarrhea can lead to dehydration and potentially elevated lithium levels and toxicity.
Diarrhea, vomiting, and lethargy can also indicate lithium toxicity. The nurse should inform the
client to stop taking the medication if the any indications of lithium toxicity occur.
65. A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of
the following statements by a staff member indicates an understanding of the teaching?
A. “The legal requirement for client confidentiality ceases if the client is deceased.”
B. “Staff members are required to divulge information to attorneys if they call for information.”
C. “Health care workers are not required to answer a court’s requests for information about a
client’s disclosure.”
D. “Providers are required to warn individuals if the client threatens harm.”
Answer: D. “Providers are required to warn individuals if the client threatens harm.”
Rationale:
A. Information that cannot legally be shared when a client is alive also cannot be shared after a
client has died.
B. Some states may require that information be provided to law enforcement or attorneys but
only with the proper documentation. Communication should then be done in person so that
identification can be verified.
C. Health care workers must answer a court’s inquiry about what a client has disclosed, even if it
indicates the client has committed a crime.
D. Health care professionals have a duty to warn and protect third party individuals who may be
in danger due to the client’s threats of harm.
66. A nurse is teaching a newly licensed nurse about appropriate actions to take when a client
threatens to harm a specific individual. Which of the following statements by the newly licensed
nurse indicates understanding?
A. “I need to make sure that the potential victim is warned.”
B. “I need to keep the information confidential due to the client’s right to privacy.”
C. “I can only discuss the client’s threats with a court order.”

D. “I should verbally report this information to the psychiatrist.”
Answer: A. “I need to make sure that the potential victim is warned.”
Rationale:
A. Healthcare professionals have a duty to warn potential victims following a client threat.
B. A threat of harm creates an exception to the client’s right to privacy.
C. A threat of harm creates an exception to the client’s right to privacy and therefore a court
order is not required to discuss the threat.
D. A client’s threat needs to be shared with the health care team and reported in the client’s
record.
67. A nurse is teaching staff which factors to include in an abuse assessment of a client. Which of
the following factors should the nurse include in the teaching? (Select all that apply.)
A. Suicide risk
B. Socioeconomic status
C. Coping patterns
D. Support systems
E. Alcohol use
Answer: A. Suicide risk
C. Coping patterns
D. Support systems
E. Alcohol use
Rationale:
A. Suicide risk is correct. The person may feel desperate and trapped and view suicide as the
only option. Any risk of harm to the client or to other people should be included in the
assessment.
B. Socioeconomic status is incorrect. Abuse can occur in all levels of socioeconomic status;
therefore, it is not necessary to include this in an abuse assessment.
C. Coping patterns is correct. Coping patterns should be included in an abuse assessment to
assess family strengths and stressors.
D. Support systems is correct. Support systems should be included in an abuse assessment, as the
person may be in a dependent and isolated situation and unaware of available support.

E. Alcohol use is correct. Alcohol and drug use should be included in an abuse assessment, as the
person may self-medicate to escape the situation.
68. A nurse is observing a newly licensed nurse as she interacts with a client regarding his
concerns about his relationship with his partner. Which of the following statements by the newly
licensed nurse requires intervention by the nurse?
A. "Tell me about the concerns that you have regarding your relationship."
B. "You should try to see your partner’s point of view before your own."
C. "We could develop a plan for how to talk about this with your partner."
D. "Relationship difficulties are stressful and require effort to resolve."
Answer: B. "You should try to see your partner’s point of view before your own."
Rationale:
A. This statement elicits information in a nonjudgmental manner which is an appropriate
communication technique.
B. This statement gives advice, which is nontherapeutic.
C. This statement encourages developing a plan of action which is an appropriate communication
technique.
D. This statement offers information in a nonjudgmental manner which is an appropriate
communication technique.
69. A client commits suicide in an acute mental health facility. Which of the following is the
priority intervention for staff following this incident?
A. Provide professional counseling for staff members.
B. Change policies for staff observation of clients who are suicidal.
C. Identify cues in the client’s behavior that might have warned them that he was contemplating
suicide.
D. Give the family an opportunity to talk about their feelings.
Answer: C. Identify cues in the client’s behavior that might have warned them that he was
contemplating suicide.
Rationale:

A. This is an appropriate intervention. However, it is not the priority when taking the nursing
process approach to client care, as assessment of staff should be done before providing
counseling.
B. This is an appropriate intervention. However, it is not the priority when taking the nursing
process approach to client care. An analysis of current policies needs to be done before changes
are made.
C. Identifying cues in the client’s behavior is the priority intervention when taking the nursing
process approach to client care. Assessment is the first step in dealing with a situation.
D. This is an appropriate intervention. However, it is not the priority when taking the nursing
process approach to client care. The family needs ongoing opportunities to process their feelings.
70. A nurse is teaching a newly licensed nurse about reporting suspected child abuse. Which of
the following statements indicates an understanding by the newly licensed nurse?
A. "Evidence must exist prior to reporting."
B. "If the potential abuser commits to stopping the abuse, health care workers are not required to
report it.”
C. "I don’t want to defame someone if the report is false."
D. "If suspicion of abuse exists then reporting is mandatory.”
Answer: D. "If suspicion of abuse exists then reporting is mandatory.”
Rationale:
A. It is not required for the healthcare workers to have evidence of abuse prior to reporting.
B. Health care workers are required to report suspected child abuse.
C. Healthcare workers are protected from civil liability for reports of abuse that are made in good
faith.
D. Healthcare workers are legally required to report any suspicions of child abuse even if
evidence does not exist.
71. A nurse is teaching about electroconvulsive therapy (ECT) with a newly licensed nurse. The
nurse should identify that the newly licensed nurse understands the teaching when she states that
ECT treats which of the following disorders?
A. Narcotic addiction

B. Vegetative depression
C. Personality disorder
D. Eating disorder
Answer: B. Vegetative depression
Rationale:
A. ECT has not been shown to be effective for the treatment of narcotic addiction.
B. ECT is an effective treatment for clients who have major depression, including clients who
have vegetative findings.
C. ECT has not been shown to be effective for the treatment of personality disorders.
D. ECT is not indicated for the treatment of eating disorders.
72. A nurse is performing an admission assessment for a client who is receiving treatment
following a situational crisis. Which of the following assessments by the nurse is the highest
priority?
A. Determining if the client has psychotic thinking
B. Asking the client to identify the cause of the crisis
C. Identifying the client's coping skills
D. Identifying the client's support systems
Answer: A. Determining if the client has psychotic thinking
Rationale:
A. Clients experiencing a situational crisis are at greatest risk for injury to themselves or others;
therefore, determining if psychotic thinking is present is the highest priority.
B. It is important to determine the cause of the crisis; however, this is not the priority, as it does
not address the greatest risk to the client.
C. It is important to identify the client's coping skills; however, this is not the priority, as it does
not address the greatest risk to the client.
D. It is important to identify the client's support systems; however, this is not the priority, as it
does not address the greatest risk to the client.
73. A nurse is assessing a client who is experiencing chronic stress. Which of the following
findings should the nurse expect?

A. Hypotension
B. Viral infection
C. Increased energy
D. Increased cognitive awareness
Answer: B. Viral infection
Rationale:
A. The nurse should expect to find the client hypertensive, not hypotensive, due to increased
cardiac tone from the response to chronic stress.
B. The nurse should expect to find the client with a decreased immune response, which leads to
viral or bacterial infections in response to chronic stress.
C. The nurse should expect the client to have decreased energy levels, not increased energy, in
response to chronic stress.
D. The nurse should expect the client to have decreased memory and ability to learn, not
increased cognitive awareness in response to chronic stress.
74. A nurse is caring for a young adult client who has acute schizophrenic disorder and tells the
nurse, "Yester noon the sun moon went over the rover to see the lawnmower." Which of the
following manifestations is the client exhibiting?
A. Delusional disorder
B. Associative looseness
C. Hallucination
D. Anhedonia
Answer: B. Associative looseness
Rationale:
A. The client who manifests delusional disorder might have a false fixed belief about a person or
situation that is believed to be real, but that is not what the client is displaying.
B. The client who is manifesting associative looseness has ideas that do not connect to each other
and are expressed in garbled and illogical speech. This is a typical disturbance for the client who
has schizophrenia.
C. The client who manifests hallucinations perceives a sensory experience with no existing
external stimulation, but that is not what the client is displaying.

D. The client who manifests anhedonia fails to experience pleasure in activities that were
previously enjoyed, but that is not what the client is displaying.
75. A nurse is assessing an adolescent client who has anorexia nervosa. Which of the following
client statements is a sign of cognitive distortion?
A. "I like to cut my food into small pieces."
B. "I really need to get into shape."
C. "If I eat one piece of candy, I may as well eat ten."
D. "I can't afford to gain weight."
Answer: C. "If I eat one piece of candy, I may as well eat ten."
Rationale:
A. The client's statement is an example of a stated behavior associated with anorexia nervosa;
therefore, this is not cognitive distortion.
B. The client's statement is an example of a stated behavior associated with anorexia nervosa;
therefore, this is not cognitive distortion.
C. he client's statement is an example that displays all-or-nothing thinking, which is a form of
cognitive distortion.
D. The client's statement is an example of a stated thought associated with anorexia nervosa;
therefore, this is not cognitive distortion.
76. A nurse is caring for a client who attacked one of her friends and is admitted to the
psychiatric unit. Which of the following actions should the nurse take first?
A. Establish a client relationship.
B. Explain to the client that the behavior was unacceptable.
C. Explore the truth of the client's statements.
D. Set behavioral limits for the client.
Answer: D. Set behavioral limits for the client.
Rationale:
A. The nurse should initiate a relationship to build trust, but it is not the priority action.
B. The nurse should explain to the client the violent behavior was unacceptable, but it is not the
priority action.

C. The nurse should explore the truth of the client's statement to prevent recurring client
response, but it is not the priority action.
D. The nurse should first set behavioral limits for the client to stop harming others.
77. A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder.
Which of the following findings should the nurse expect?
A. Rapid speech
B. Chills
C. Distorted perceptual field
D. Urinary frequency
Answer: D. Urinary frequency
Rationale:
A. The nurse should expect the client who has severe anxiety disorder to exhibit rapid speech.
B. The nurse should expect the client who has a panic level of anxiety to exhibit chills and
trembling.
C. The nurse should expect the client who has severe anxiety disorder to have a distorted
perceptual field.
D. The nurse should expect the client who has moderate anxiety disorder to exhibit urinary
frequency, as well as headache, backache, and insomnia.
78. A nurse in the emergency department is implementing a plan of care for an older adult client
who is experiencing delirium tremens. Which of the following actions should the nurse take
first?
A. Administer diazepam.
B. Raise the side rails of the bed.
C. Obtain a medical history.
D. Start intravenous fluids.
Answer: B. Raise the side rails of the bed.
Rationale:
A. The nurse should administer diazepam when the client is safe; therefore, this is not a priority
action.

B. The greatest risk to the client is injury from a fall; therefore, the first action by the nurse is to
raise the side rails of the bed.
C. The nurse should obtain a medical history after making sure the client is safe; therefore, this is
not a priority action.
D. The nurse should make the sure the client is safe before starting intravenous fluids; therefore,
this is not a priority action.
79. A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The
client's head down, and he is wringing his hands. Which of the following actions should the
nurse take?
A. Encourage the client to go back to bed.
B. Give the client a PRN sleeping medication.
C. Remain with the client.
D. Explore alternatives to pacing the floor with the client.
Answer: C. Remain with the client.
Rationale:
A. A client who is experiencing severe level of anxiety will not respond positively to going back
to bed.
B. A client who is given a PRN sleeping medication will not be alleviated of severe anxiety. This
action will only temporarily suppress the feelings.
C. Remaining nearby the client will help to alleviate feelings of abandonment and reassures the
client of his safety.
D. A client who is experiencing severe anxiety will not respond to exploring alternatives to
pacing.
80. A nurse is performing an admission assessment for a client who has schizophrenia. Which of
the following findings should the nurse identify as a negative symptom?
A. Affective flattening
B. Bizarre behavior
C. Illogicality
D. Somatic delusions

Answer: A. Affective flattening
Rationale:
A. Affective flattening is an example of a negative symptom of schizophrenia.
B. Bizarre behavior is an example of a positive symptom of schizophrenia.
C. Illogicality is an example of a positive symptom of schizophrenia.
D. Somatic delusions are an example of a positive symptom of schizophrenia.
81. A nurse is caring for a client who has schizophrenia and is experiencing a variety of
hallucinations. Which of the following hallucinations is the priority for the nurse to address?
A. Visual hallucination
B. Gustatory hallucination
C. Command hallucination
D. Tactile hallucination
Answer: C. Command hallucination
Rationale:
A. Visual hallucinations are an important finding; however, they do not pose the greatest risk and
therefore are not the priority concern.
B. Gustatory hallucinations are an important finding; however, they do not pose the greatest risk
and therefore are not the priority concern.
C. Gustatory hallucinations are an important finding; however, they do not pose the greatest risk
and therefore are not the priority concern.
D. Tactile hallucinations are an important finding; however, they do not pose the greatest risk and
therefore are not the priority concern.
82. A nurse in an acute mental health facility is creating a plan of care for a new client who has
histrionic personality disorder. Which of the following is the priority intervention for the nurse to
make?
A. Promote appropriate behavior during group therapy sessions.
B. Encourage client input in the treatment plan.
C. Communicate with the client using concrete language.
D. Demonstrate assertive behavior.

Answer: A. Promote appropriate behavior during group therapy sessions.
Rationale:
A. Managing the client's behavior within the group is the priority intervention for the client who
has histrionic personality disorder because these clients display extreme attention-seeking
behaviors and are often impulsive, which can be extremely disruptive in a group setting with
other members.
B. This is an appropriate intervention; however, it is not the priority for the client who has
histrionic personality disorder.
C. This is an appropriate intervention; however, it is not the priority for the client who has
histrionic personality disorder.
D. This is an appropriate intervention; however, it is not the priority for the client who has
histrionic personality disorder.
83. A nurse is caring for a client who has delusional behavior and states, "I can't go to group
therapy today. I am expecting a high level official to visit me!" The nurse responds, "I
understand, but it is time for group therapy and we expect everyone to attend. Let's walk over
together." For which of the following reasons is the nurse's response considered therapeutic?
A. It clearly articulates what is expected of the client.
B. It demonstrates empathy towards the client.
C. It sets limits on the client's manipulative behavior.
D. It uses reflection when talking with the client.
Answer: A. It clearly articulates what is expected of the client.
Rationale:
A. This response is therapeutic because it clearly states what is expected of the client without
arguing. The nurse also offers self by offering to walk with the client.
B. Empathy is appropriate for client care; however, this statement is not an example of
empathetic communication.
C. The client is demonstrating delusional thinking rather than manipulative behavior.
D. Reflection is appropriate for client care; however, this statement is not an example of this
therapeutic communication technique.

84. A nurse is discussing the manifestations of alcohol withdrawal with a client who has a history
of alcohol use disorder. Which of the following client statements indicates understanding?
A. "I should expect tremors to start less than 24 hours after I stop drinking."
B. "Disulfiram will block my cravings for alcohol."
C. "My symptoms should last about 5 to 7 days once they begin."
D. "It is important that I take vitamin C to prevent cirrhosis or other liver damage."
Answer: A. "I should expect tremors to start less than 24 hours after I stop drinking."
Rationale:
A. Signs of withdrawal might develop within a few hours of the client's last drink of alcohol.
B. Disulfiram deters alcohol intake by producing unpleasant adverse effects when alcohol is
consumed; however, it does not block cravings.
C. Manifestations of alcohol withdrawal usually peak within 24 to 48 hr and then rapidly
disappear.
D. Vitamin C does not prevent cirrhosis or other liver damage associated with alcohol abuse.
85. A nurse is caring for a group of clients in an acute mental health facility. Which of the
following clients has the legal right to refuse treatment?
A. A 16-year-old client whose parents have requested treatment
B. An adult client who has delusions and refuses treatment for religious reasons
C. An older adult client who was voluntarily admitted
D. A client who is competent but was involuntarily admitted
Answer: C. An older adult client who was voluntarily admitted
Rationale:
A. Minors are unable to refuse treatment unless they are emancipated minors.
B. Incompetent clients are unable to refuse treatment.
C. Competent clients admitted voluntarily are legally able to refuse treatment at any time during
the course of their care.
D. Clients who are admitted involuntarily are unable to refuse treatment.
86. A nurse is caring for a client who has a mental illness. Which of the following actions by the
nurse demonstrates the ethical concept of autonomy?

A. Encouraging client feedback about satisfaction with the facility experience
B. Explaining unit rules and policies regarding unacceptable behaviors
C. Supporting the client's wish to refuse prescribed medications
D. Making sure the client understands expectations for client participation
Answer: C. Supporting the client's wish to refuse prescribed medications
Rationale:
A. This intervention demonstrates the ethical concept of fidelity.
B. This intervention demonstrates the ethical concept of veracity.
C. Supporting the client's wishes is an important component of client advocacy.
D. This intervention demonstrates the ethical concept of veracity.
87. A nurse in a rehabilitation center is planning care for a newly admitted client who has a
history of alcohol use disorder. Which of the following client goals is the highest priority?
A. The client will acknowledge alcohol dependence and need for treatment.
B. The client will rebuild damaged interpersonal relationships.
C. The client will implement alternative strategies for managing anxiety.
D. The client's withdrawal from alcohol will be managed without complications.
Answer: D. The client's withdrawal from alcohol will be managed without complications.
Rationale:
A. This goal is appropriate for client care; however, it does not address the greatest risk to the
client and is therefore not the priority.
B. This goal is appropriate for client care; however, it does not address the greatest risk to the
client and is therefore not the priority.
C. This goal is appropriate for client care; however, it does not address the greatest risk to the
client and is therefore not the priority.
D. The greatest risk to the client is injury and adverse effects of withdrawal; therefore, this goal
is the highest priority.
88. A nurse is providing teaching about confidentiality with a newly licensed nurse. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching?
A. "The courts might require me to discuss confidential information."

B. "I am required to provide confidential information to insurance companies."
C. "If questioned during a police investigation, I am required to divulge confidential
information."
D. "I am legally allowed to discuss confidential information with the client's former therapist."
Answer: A. "The courts might require me to discuss confidential information."
Rationale:
A. In some states, the court may enact a court order requiring the nurse to discuss confidential
client information.
B. The nurse is not legally required to discuss confidential client information in this situation;
doing so would go against the client's right to privacy.
C. The nurse is not legally required to discuss confidential client information in this situation;
doing so would go against the client's right to privacy.
D. The nurse is not legally required to discuss confidential client information in this situation;
doing so would go against the client's right to privacy.
89. A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD).
Which of the following actions should the nurse take first?
A. Discuss alternative coping strategies with the client.
B. Identify precipitating factors for ritualistic behaviors.
C. Instruct the client on relaxation techniques for use when anxiety increases.
D. Provide a structured activity schedule for the client.
Answer: B. Identify precipitating factors for ritualistic behaviors.
Rationale:
A. This is an appropriate intervention; however, it is not the priority when taking the nursing
process approach to client care.
B. This is the priority intervention when taking the nursing process approach to client care.
C. This is an appropriate intervention; however, it is not the priority when taking the nursing
process approach to client care.
D. This is an appropriate intervention; however, it is not the priority when taking the nursing
process approach to client care.

90. A nurse is assessing a family as a system. Which of the following factors should the nurse
include when assessing sociocultural context?
A. The sense of self among individual family members
B. The future goals of the family
C. The roles of family members
D. The family's religious practices
Answer: D. The family's religious practices
Rationale:
A. This is appropriate when assessing the differentiation of the family.
B. This is appropriate when assessing the life cycle of the family.
C. This is appropriate when assessing the hierarchy of the family.
D. This is appropriate when assessing the sociocultural context of the family.
91. A nurse is caring for a young adult client following the sudden death of his wife. The client
feels paralyzed in his ability to cope with work and family responsibilities. Which of the
following types of crisis is the client experiencing?
A. Situational
B. Maturational
C. Adventitious
D. Developmental
Answer: A. Situational
Rationale:
A. This client situation is an example of a situational crisis which refers to loss or change that is
often unexpected.
B. A maturational crisis refers to a crisis involving new stages of growth and development.
C. An adventitious crisis refers to a crisis such as a natural disaster or act of violence.
D. A developmental crisis refers to a crisis involving new stages of growth and development.
92. A nurse is caring for a client who has schizophrenia. Which of the following statements by
the client indicates understanding of a relapse prevention plan?
A. “I can remember when my hallucinations first began.”

B. “I know which of my hallucinations trigger a relapse.”
C. “I record the number of hallucinations I have each day.”
D. “I will read as much information as I can about schizophrenia.”
Answer: B. “I know which of my hallucinations trigger a relapse.”
Rationale:
A. This statement indicates an understanding of the disorder but does not address a relapse
prevention plan.
B. This statement indicates a client’s understanding of relapse triggers and is an important
component of a relapse prevention plan.
C. This statement indicates an understanding of the management of schizophrenia but does not
address a relapse prevention plan.
D. This statement indicates a desire to gain knowledge regarding schizophrenia but does not
address a relapse prevention plan.
93. A nurse is caring for a client who has schizophrenia who consistently does the opposite of
what the nurse asks of him. The nurse recognizes this as which of the following alterations in
behavior?
A. Automatic obedience
B. Waxy flexibility
C. Active Negativism
D. Impaired impulse control
Answer: C. Active Negativism
Rationale:
A. Automatic obedience is the performance of simple commands in a machine-like manner.
B. Waxy flexibility is the continuation of a posture in a statue-like manner.
C. The nurse identifies this behavior by the client as active negativism.
D. Impaired impulse control is the inability to control impulses.
94. A nurse is caring for a client who has schizophrenia. Which of the following statements by
the client indicates concrete thinking?
A. “I am aware that each problem has only one solution.”

B. "I am a prophet of the most high king."
C. “The voices tell me that I must avoid large crowds.”
D. “I know that you and the other nurses are trying to poison me.”
Answer: A. “I am aware that each problem has only one solution.”
Rationale:
A. This statement is an example of concrete thinking which refers to the client’s inability to think
abstractly.
B. This statement is an example of a delusion and grandiosity.
C. This statement is an example of an auditory hallucination.
D. This statement is an example of paranoia.
95. A nurse is caring for a client who professes a deep and everlasting love for his girlfriend one
day, and the next day refuses to speak to her or allow her to visit. The nurse recognizes this client
behavior which of the following defense mechanisms?
A. Repression
B. Splitting
C. Sublimation
D. Undoing
Answer: D. Undoing
Rationale:
A. Repression is an unconscious forgetting of an unpleasant or unwanted experience or emotion.
B. Splitting is the inability to combine both positive and negative qualities of an individual.
C. Sublimation is an unconscious mechanism of substituting an unacceptable impulse with one
that is acceptable.
D. The nurse correctly identifies this as an example of undoing which is the attempt to make up
for or reverse prior behavior.
96. A nurse is counseling a client for the management of anxiety. The client is consistently late
for appointments and ignores household chores. The client states, "I'm just too stressed. I need
someone to take care of me." The nurse identifies this behavior as an example of which of the
following defense mechanisms?

A. Dissociation
B. Introjection
C. Regression
D. Repression
Answer: C. Regression
Rationale:
A. Dissociation is the ability to compartmentalize.
B. Introjection is incorporating outside factors into oneself.
C. This is an example of regression which is the mechanism of reverting to childlike or immature
behaviors.
D. Repression is the unconscious ability of the mind to forget a stressor.
97. A nurse is assessing a client who is withdrawing from alcohol. Which of the following
findings should the nurse expect? (Select all that apply).
A. Severe hypotension
B. Visual hallucinations
C. Hyperglycemia
D. Insomnia
E. Tremors
Answer: B. Visual hallucinations
D. Insomnia
E. Tremors
Rationale:
A. Severe hypotension is incorrect. Elevated blood pressure, rather than hypotension, is an
expected finding with alcohol withdrawal.
B. Visual hallucinations is correct. Visual and auditory hallucinations are expected findings with
alcohol withdrawal.
C. Hyperglycemia is incorrect. Clients undergoing alcohol withdrawal can develop
hypoglycemia, rather than hyperglycemia, as a complication of this process.
D. Insomnia is correct. Insomnia, restlessness, and irritability are common manifestations of
alcohol withdrawal.

E. Tremors is correct. Tremors and sweating are expected findings with alcohol withdrawal.
98. A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the
following actions should the nurse take? (Select all that apply).
A. Avoid eye contact to prevent escalation of anxiety.
B. Establish rapport with the client.
C. Identify the cause of the anxiety.
D. Validate the client's feelings.
E. Develop a flexible crisis intervention plan.
Answer: B. Establish rapport with the client.
C. Identify the cause of the anxiety.
D. Validate the client's feelings.
Rationale:
A. Avoiding eye contact inhibits the nurse-client relationship and does not assist in establishing
rapport.
B. Establishing a rapport with the client is an appropriate crisis intervention.
C. Identifying the cause of the anxiety is an appropriate crisis intervention.
D. Validating the client’s feelings is an appropriate crisis intervention.
E. Developing a concrete crisis intervention plan, rather than one that is flexible, is an
appropriate crisis intervention.
99. A nurse is caring for a client who has dementia. When performing a Mental Status
Examination (MSE) the nurse should include which of the following data? (Select all that apply.)
A. Ability to perform calculations
B. Coping skills
C. Recall ability
D. Long-term memory
E. Level of orientation
Answer: A. Ability to perform calculations
C. Recall ability
D. Long-term memory

E. Level of orientation
Rationale:
A. Ability to perform calculations is correct. Evaluating the clients ability to perform calculations
is an included component of an MSE.
B. Coping skills is incorrect. Determining the clients coping ability is not a component of an
MSE.
C. Recall ability is correct. Identifying the clients ability to recall a list of objects or words is an
included component of an MSE.
D. Long-term memory is correct. Evaluating long-term, or remote, memory is an included
component of an MSE.
E. Level of orientation is correct. Determining the clients level of orientation is an included
component of an MSE.
100. A nurse is caring for a client who was admitted with delirium tremens five days ago. The
client seeks permission from the nurse before performing activities of daily living. This behavior
indicates which of the following findings to the nurse?
A. The client is ready for discharge.
B. The client may be having a recurrence of delirium tremens.
C. The client is able to function independently.
D. The client is exhibiting dependency.
Answer: D. The client is exhibiting dependency.
Rationale:
A. Seeking permission to complete activities of daily living does not indicate the client is ready
for discharge. The client should be able to function independently prior to discharge.
B. Seeking permission to complete activities of daily living is not a manifestation of delirium
tremens, and does not indicate a recurrence may be occurring.
C. Seeking permission to complete activities does not indicate the client is able to function
independently. Independence is exhibited by an ability to make decisions without guidance or
input from others.
D. Seeking permission for simple tasks indicates dependent functioning.

101. A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which
of the following findings supports the admitting diagnosis of acute mania?
A. The client’s spouse reports that client has recently gained weight.
B. The client is dressed in all black.
C. The client responds to questions with disorganized speech.
D. The client reports that voices are telling him to write a novel.
Answer: C. The client responds to questions with disorganized speech.
Rationale:
A. Clients who are experiencing acute mania typically have weight loss rather than weight gain.
B. Clients who are experiencing acute mania typically present with bizarre, uncoordinated dress.
C. Clients who are experiencing acute mania exhibit disorganized speech such as a flight of
ideas.
D. A client report of voices is typical of schizophrenia rather than acute mania.
102. A nurse is admitting a client who is exhibiting manic behavior. The client reports recent
personal stressors including the loss of her mother and a divorce. Which of the following is the
priority nursing action?
A. Identifying support systems.
B. Assisting the client in identifying coping behaviors.
C. Encouraging self-care
D. Preventing self-directed violence.
Answer: D. Preventing self-directed violence.
Rationale:
A. Identifying support systems is an appropriate action. However, it does not address the greatest
safety risk to the client and is therefore not the priority.
B. Identifying coping behaviors is an appropriate action. However, it does not address the
greatest safety risk to the client and is therefore not the priority.
C. Encouraging self-care is an appropriate action. However, it does not address the greatest
safety risk to the client and is therefore not the priority.
D. Prevention of injury addresses the greatest safety risk to the client and is therefore the priority
action.

103. A nurse in the emergency department is caring for a client who reports chest pain, headache,
and shortness of breath. He continues to state, “I don’t know why my wife left me.” The client
receives a diagnosis of anxiety. The nurse realizes the client’s findings support which level of
anxiety?
A. Mild
B. Moderate
C. Severe
D. Panic
Answer: C. Severe
Rationale:
A. Mild anxiety causes mild physical symptoms, rather than chest pain and shortness of breath.
B. Moderate anxiety may cause a pounding heart, but is not associated with chest pain or the
client’s other presenting symptoms.
C. Chest pain, headache, shortness of breath, and focus on one particular item are all findings
associated with severe anxiety.
D. Panic level of anxiety causes the client to lose touch with reality and is associated with
unintelligible speech or the inability to speak.
104. A nurse is caring for a client who is terminally ill and exhibiting signs of impending death.
The client’s medical record states that the client is a practicing Roman Catholic. Which of the
following nursing actions is appropriate?
A. Offer to make arrangements for the Sacrament of the Sick
B. Prepare to stay with the client’s body after death until family arrives.
C. Arrange for a member of the client’s faith to bathe the body after death.
D. Post a sign on the client’s door stating, “No Talking”.
Answer: A. Offer to make arrangements for the Sacrament of the Sick
Rationale:
A. Practicing Roman Catholics often wish to receive the Sacrament of the Sick from a priest
during times of illness or when death is approaching.

B. Clients who practice Judaism, rather than Catholicism, believe that the body should not be left
unattended until after the funeral.
C. Clients who practice Islam, rather than Catholicism, believe that an individual from the
client’s mosque should perform bathing rituals after death.
D. Posting a sign on the client’s door is a potential breach of confidentiality. Roman Catholics do
not require a quiet room based on beliefs.
105. A nurse is caring for a client who has an eating disorder. The nurse is practicing which of
the following ethical concepts when the client refuses to drink a between meal protein and
calorie supplement?
A. Autonomy
B. Beneficence
C. Veracity
D. Fidelity
Answer: A. Autonomy
Rationale:
A. Autonomy respects the rights of clients to refuse medication or treatment.
B. Beneficence refers to actions that promote the well-being of others.
C. Veracity refers to the ethical principle of being truthful with clients.
D. Fidelity refers to the ethical principle of doing no wrong to clients.
106. A nurse is caring for a client who has autism spectrum disorder. Which of the following
findings should the nurse expect?
A. Expressive affect
B. Associative looseness
C. Echolalia
D. Ambivalence
Answer: C. Echolalia
Rationale:
A. An expressive affect is a fundamental sign of schizophrenia, but is manifested through
inappropriate emotional reactions

B. Associative looseness is a fundamental sign of schizophrenia, but is manifested through
disorganized thoughts and speech patterns.
C. Autism is a fundamental sign of autism spectrum disorder and is manifested through thought
patterns that are not based on reality.
D. Ambivalence is a fundamental sign of schizophrenia, but is manifested through the
simultaneous expression of two opposing attitudes or emotions.
107. A nurse is discussing obsessive-compulsive disorder (OCD) with a newly licensed nurse.
Which of the following statements by the newly licensed nurse indicates an understanding of the
underlying reason clients with OCD perform ritualistic behaviors?
A. “The ritualistic behavior provides sexual satisfaction.”
B. “The client performs ritualistic behavior to boost self-esteem.”
C. “The ritualistic behavior temporarily relieves anxiety.”
D. “The client performs ritualistic behavior to decrease feelings of shame.”
Answer: C. “The ritualistic behavior temporarily relieves anxiety.”
Rationale:
A. Ritualistic behaviors may involve sexuality issues, but the purpose of the behavior is not to
provide sexual satisfaction.
B. Ritualistic behaviors typically cause the client to feel humiliation, and therefore do not raise
self-esteem.
C. Clients with OCD perform ritualistic behaviors to provide a temporary relief from anxiety
related to obsessions.
D. Ritualistic behaviors cause an increase, rather than a decrease, in the client’s feelings of
shame.
108. A nurse is performing a mental status examination (MSE) on a client who has a new
diagnosis of dementia. Which of the following components should the nurse include? (Select all
that apply.)
A. Grooming
B. Long-term memory
C. Support systems

D. Affect
E. Presence of pain
Answer: A. Grooming
B. Long-term memory
D. Affect
Rationale:
A. Grooming is included in an MSE which consists of appearance, behavior, speech, mood,
disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or
others.
B. Long-term memory is included in an MSE which consists of appearance, behavior, speech,
and mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of
harming self or others.
C. Support systems are not included in an MSE which consists of appearance, behavior, speech,
mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming
self or others.
D. Affect is included in an MSE which consists of appearance, behavior, speech, and mood,
disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or
others.
E. The presence of pain is not included in an MSE which consists of appearance, behavior,
speech, mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of
harming self or others.
109. A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the
following findings should the nurse expect?
A. Tachycardia
B. Constipation
C. Metrorrhagia
D. Hyperkalemia
Answer: B. Constipation
Rationale:
A. Bradycardia, rather than tachycardia, is an expected finding of anorexia nervosa.

B. Constipation is an expected finding of anorexia nervosa due to the effects of starvation.
C. Amenorrhea, rather than metrorrhagia, is an expected finding of anorexia nervosa.
D. Hypokalemia, rather than hyperkalemia, is an expected finding of anorexia nervosa.
110. A charge nurse is preparing an educational session about addictive disorders for nursing
staff. Which of the following should the nurse include as an etiological factor of addictive
disorders? (Select all that apply).
A. Being female
B. Low self-esteem
C. Family history of addiction
D. Personality disorders
E. Asian ethnicity
Answer: B. Low self-esteem
C. Family history of addiction
D. Personality disorders
Rationale:
A. There is a higher rate of addictive disorders in men versus women.
B. Low self-esteem is considered a psychological factor associated with addictive disorders.
C. Family history of addiction is an etiological factor associated with addictive disorders.
D. Research supports the link between personality disorders and addictive disorders.
E. Clients of Asian ethnicity have a lower rate of addictive disorders compared to other
ethnicities.
111. A nurse is caring for a client who is to start chemotherapy for advanced breast cancer. She
tells the nurse she is worried about the adverse effects of the treatment. Which of the following
responses should the nurse make?
A. "I will have your provider discuss the adverse effects with you before the treatment begins."
B. "Someone from the American Cancer Society will be here soon to answer your questions."
C. "What is it about the adverse effects that concern you?"
D. "I agree. Sometimes the adverse effects can be worse than the disease."
Answer: C. "What is it about the adverse effects that concern you?"

Rationale:
A. By offering to pass the client's concerns to someone else, the nurse is demonstrating that she
does not wish to discuss them with the client. This is a dismissive action.
B. By offering to pass the client's concerns to someone else, the nurse is demonstrating that she
does not wish to discuss them with the client. This is a dismissive action.
C. With this response, the nurse takes responsibility for answering the client's concerns rather
than passing them to someone else. It also exemplifies the therapeutic communication technique
of exploring, as it invites the client to share her concerns.
D. This response illustrates the nontherapeutic communication technique of agreeing, and it also
might increase the client's concerns.
112. A nurse is caring for a client whose partner is requesting to bring the client food from home
that is not allowed in the client's dietary plan. Which of the following responses should the nurse
make?
A. "Why would you want to put your partner's health at further risk?"
B. "Everyone likes food from home, but it can delay your partner's recovery."
C. "You will need to discuss your concerns about your partner's diet with the provider."
D. "Let's try to find ways to incorporate your partner's favorite food into her diet plan."
Answer: D. "Let's try to find ways to incorporate your partner's favorite food into her diet plan."
Rationale:
A. This response illustrates the nontherapeutic communication technique of requesting an
explanation. Asking "why" questions can be intimidating and might cause the partner to become
defensive.
B. This response illustrates the nontherapeutic communication technique of belittling the
partner's feelings and demonstrates a lack of empathy.
C. By offering to pass the partner's concerns to someone else, the nurse is demonstrating that she
does not wish to discuss the issue. This is a dismissive action.
D. This response illustrates the therapeutic communication technique of formulating a plan of
action. It demonstrates the nurse's willingness to work with the partner to modify the proposal so
that it meets the client's dietary needs at this time.

113. A nurse is speaking with the parents of a 4-year-old child who has a terminal illness. The
parents tell the nurse they have taken their son’s name off the list for little league baseball next
season. Which of the following responses should the nurse make?
A. "It must be frustrating for you to have to cancel an activity your son enjoyed."
B. "Baseball can be a dangerous sport for children anyway."
C. "You never know. He could be ready for baseball by the spring."
D. "Why did you feel you needed to do that at this time?"
Answer: A. "It must be frustrating for you to have to cancel an activity your son enjoyed."
Rationale:
A. This response demonstrates the therapeutic communication technique of sharing empathy. It is
neutral and nonjudgmental and invites further communication and sharing.
B. This response is stereotypical and fails to convey empathy and understanding.
C. With this response, the nurse gives the parents false reassurance, which is a nontherapeutic
communication technique.
D. This response illustrates the nontherapeutic communication technique of asking "why"
questions. This can make the parent's defensive and decrease communication between them and
the nurse.
114. A nurse notices that a client who has moderate anxiety is pacing the hall and mumbling As
the nurse approaches the client, he states, "I am at the end of my rope. I don't think I can take any
more bad news." Which of the following responses should the nurse make?
A. "Most clients with anxiety issues benefit from lying down."
B. "Come with me to an area where we can talk without interruption."
C. "Providers usually recommend relaxation exercises for clients who are as upset as you are."
D. "An antianxiety pill works best for situations like this."
Answer: B. "Come with me to an area where we can talk without interruption."
Rationale:
A. This response demonstrates the nontherapeutic communication technique of minimizing
feelings. Generalizing what the client is experiencing shows a lack of empathy, and the nurse is
not exploring what is bothering the client.

B. With this response, the nurse illustrates the therapeutic communication technique of offering
herself. She demonstrates empathy by respecting the client's privacy and showing her willingness
to listen.
C. This response demonstrates the nontherapeutic communication technique of minimizing
feelings. Generalizing what the client is experiencing shows a lack of empathy, and the nurse is
not exploring what is bothering the client.
D. This response illustrates that the nurse would rather suppress the client's feelings and
expression of feelings by administering medication. Although it might become necessary to give
the client medication, the nurse should not suggest this without first exploring what is wrong
with the client and trying to help the client in less restrictive ways.
115. A nurse is caring for an older adult client who had a cerebrovascular accident and has rightsided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist
that his mother live with him. Which of the following responses should the nurse make?
A. "So, it seems that you feel responsible for what happened to your mother."
B. "Your mother will be fine. You shouldn't worry so much."
C. "Why do you blame yourself? You could not have prevented the stroke."
D. "You are not responsible for your mother's stroke, but many people in your situation feel this
way."
Answer: A. "So, it seems that you feel responsible for what happened to your mother."
Rationale:
A. This response demonstrates the therapeutic communication technique of reflecting. It directs
feelings back to the son in a way that shows interest and caring and encourages further
communication.
B. With this response, the nurse illustrates the nontherapeutic communication technique of
falsely reassuring.
C. This response demonstrates the nontherapeutic communication technique of disagreeing or
disapproving and also asking "why" questions, thus negating or disregarding the client's feelings.
D. This response demonstrates the nontherapeutic communication technique of disagreeing or
disapproving and comparing his situation to others, thus negating or disregarding the client's
feelings.

116. A nurse is caring for a postpartum client who tells the nurse that she does not want any more
children. The client asks which birth control method the nurse would recommend. Which of the
following responses should the nurse make?
A. "It's your choice, of course, but birth control pills are the most reliable."
B. "Your provider usually recommends a diaphragm and spermicidal cream."
C. "I'd consider an intrauterine device. You won't have to worry about pregnancy."
D. "Let's talk about the available options and go from there."
Answer: D. "Let's talk about the available options and go from there."
Rationale:
A. This response illustrates the nontherapeutic communication technique of choosing for the
client rather than assisting the client in making choices.
B. This response passes the client's question on to another without offering any information to
help her make an informed choice.
C. This response illustrates the nontherapeutic communication technique of giving personal
opinions.
D. This response illustrates the therapeutic communication technique of formulating a plan of
action. It demonstrates the nurse's willingness to provide information so that the client can make
an informed choice that will meet her needs at this time.
117. A nurse is caring for an older adult client who had a cerebrovascular accident and has leftsided weakness. The client’s partner tells the nurse she is worried about the next steps of
treatment for her partner. Which of the following responses should the nurse make?
A. "We have begun plans to send your partner to a rehabilitation facility as soon as he is stable."
B. "Your partner is too critical to consider what tomorrow will bring. Let's just concentrate on
today."
C. "Don't worry. Most clients like your partner start making progress after a few days of rest."
D. "You will have to speak to the provider for that information. I can arrange that for you."
Answer: A. "We have begun plans to send your partner to a rehabilitation facility as soon as he
is stable."
Rationale:

A. This response illustrates the therapeutic communication technique of giving information. It
directly addresses the partner's concern and demonstrates that discharge and rehabilitation
planning begin on admission.
B. This response illustrates the nontherapeutic communication technique of giving an aggressive
response. By stating that he is too critical to plan not only dismisses the partner but also instills
fear unnecessarily.
C. This response illustrates the nontherapeutic communication technique of giving false
reassurance.
D. This response passes the client's question on to another without offering any information to
help address her concerns.
118. A nurse is caring for a client who has rheumatoid arthritis and tells the nurse that she wears
a copper bracelet to help her feel better. Which of the following responses should the nurse
make?
A. "Yes, I understand that you feel better wearing your bracelet."
B. "Why do you think the copper helps with your arthritis?"
C. "Believing objects have powers to make you feel better has no scientific basis."
D. "I think you should rely more on your medication therapy than on your bracelet."
Answer: A. "Yes, I understand that you feel better wearing your bracelet."
Rationale:
A. The nurse illustrates the therapeutic communication technique of accepting. The nurse
demonstrates the knowledge that the bracelet is harmless for the client and shows respect for the
client's beliefs.
B. This response illustrates the nontherapeutic communication technique of requesting an
explanation. Asking "why" questions can be intimidating and might cause the client to become
defensive.
C. This response illustrates the nontherapeutic communication techniques of rejecting and
belittling the client's feelings. Because wearing a bracelet is harmless, there is no need for the
nurse to refute the client's belief that it helps her.

D. This response illustrates the nontherapeutic communication technique of giving advice. It
shows that the nurse thinks he knows best and thinks the client is not knowledgeable about
managing her disorder.
119. A nurse is providing discharge teaching for a client who has multiple medication
prescriptions and must take the medications at specific intervals when at home. Which of the
following instructions should the nurse include in the teaching?
A. "You really shouldn't change the schedule we established here in the facility."
B. "Let's work together to devise a time schedule that is convenient for you on a daily basis."
C. "We'll have to talk to your provider about switching to an alternative schedule."
D. "It doesn't really matter what time you take your medications as long as you don't skip any
doses."
Answer: B. "Let's work together to devise a time schedule that is convenient for you on a daily
basis."
Rationale:
A. With this response, the nurse is being unnecessarily rigid. Insisting on a schedule that worked
in the facility setting might put the client at risk for nonadherence.
B. This response illustrates the therapeutic communication technique of formulating a plan of
action. It demonstrates the nurse's willingness to work with the client to modify the schedule so
that it meets the client's needs at this time.
C. It is not necessary for the provider to approve the scheduling of specific dosage times, just the
frequency or intervals, which would already be in the prescriptions.
D. No matter what time schedule the client follows, it is still possible to skip a dose. This is a
different issue that the nurse should address separately.
120. A nurse is admitting a client who is about to undergo surgery for benign prostatic
hypertrophy. The client states, "I don't know what I will do if they find I have cancer." Which of
the following responses should the nurse make?
A. "Why do you think you might have cancer when your diagnosis is a benign condition?"
B. "I'm looking at your chart here and I don't see any reason for you to worry about that."
C. "I think that's something you need to discuss with your provider."

D. "I'm hearing that you are concerned that it might turn out that you have cancer."
Answer: D. "I'm hearing that you are concerned that it might turn out that you have cancer."
Rationale:
A. This response illustrates the nontherapeutic communication technique of requesting an
explanation. Asking "why" questions can be intimidating and might cause the client to become
defensive.
B. This response illustrates the nontherapeutic communication technique of giving reassurance.
C. By offering to pass the client's concerns to someone else, the nurse is demonstrating that she
does not wish to discuss the issue. This is a dismissive action.
D. This response illustrates the therapeutic communication techniques of seeking clarification
and restating. It demonstrates the nurse's willingness to explore the client's fears and encourages
communication.
121. A nurse is caring for a client who reports bilateral knee pain after hiking this past weekend
in the mountains on rough ground. He says he is concerned because his cousin died from bone
cancer recently. Which of the following actions should the nurse take?
A. Tell the client that it is unlikely that he has bone cancer.
B. Ask the client why he thinks the pain isn't a result of hiking.
C. Suggest genetic testing so the client can understand his risks.
D. Explain that the provider will see him and determine a course of action.
Answer: D. Explain that the provider will see him and determine a course of action.
Rationale:
A. This response illustrates the nontherapeutic communication technique of giving false
reassurance. At this point, the nurse cannot be sure that the client doesn't have bone cancer.
B. This response illustrates the nontherapeutic communication technique of requesting an
explanation. Asking "why" questions can be intimidating and might cause the client to become
defensive.
C. It is premature to suggest that the client could benefit from genetic testing, and it does not
address the client's immediate need.

D. This response illustrates the therapeutic communication technique of focusing the client on
the usual course of action that must precede drawing any conclusions about the cause of the
client's pain.
122. A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety.
After showing the client to his room, which of the following nursing actions is most therapeutic
at this time?
A. Suggest that the client rest in bed.
B. Remain with the client for a while.
C. Medicate the client with a sedative.
D. Have the client join a therapy group.
Answer: B. Remain with the client for a while.
Rationale:
A. This is an appropriate intervention after the nurse helps reduce the client's anxiety level, but it
is not the priority at this time.
B. The nurse should not leave a client who has severe anxiety alone. The nurse's priority is to use
the least restrictive intervention, such as staying with the client and calmly encouraging him to
express his feelings.
C. It may be helpful to administer a sedative to the client, but this is a restrictive intervention that
is not the priority at this time.
D. When the client's anxiety peaks, interaction with other clients might provoke him further and
his anxiety might escalate. This is an appropriate intervention later on, but not at this time.
123. A nurse on an inpatient mental health unit is caring for a client who has major depressive
disorder and malnutrition. Which of the following actions should the nurse take to improve the
client's nutritional status?
A. Enroll the client in a nutritional class on the unit.
B. Weigh the client at the same time every morning.
C. Ask provider to arrange a consultation with the facility chaplain.
D. Sit with the client during meals and snacks.
Answer: D. Sit with the client during meals and snacks.

Rationale:
A. A client who has major depression is unlikely to be receptive to learning about the importance
of nutrition.
B. It is important for the nurse to document data about the client's nutritional status, but this is
not an intervention that will help the client improve his nutritional status.
C. A consultation with the facility chaplain might yield some good suggestions for helping the
client, but it is not a nursing intervention that will help the client improve his nutritional status.
D. A change in appetite is a major symptom of depression. Being present during meals and
snacks to support and encourage the client is an appropriate nursing intervention that might help
the client at this time.
124. A nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa
and has a body mass index of 17.2. Which of the following actions should the nurse take? (Select
all that apply.)
A. Provide the client with small meals frequently.
B. Monitor the client's weight daily.
C. Allow the client to choose the meals she will eat.
D. Stay with the client during meals and for 1 hr afterward.
E. Offer specific privileges for sustained weight gain.
Answer: A. Provide the client with small meals frequently.
B. Monitor the client's weight daily.
D. Stay with the client during meals and for 1 hr afterward.
E. Offer specific privileges for sustained weight gain.
Rationale:
A. Provide the client with small meals frequently is correct. Clients who have anorexia generally
will not consume large meals.
B. Monitor the client's weight daily is correct. Daily weighing makes it difficult for the client to
hide weight loss.
C. Allow the client to choose the meals she will eat is incorrect. The BMI in the underweight
category is the result of the client choosing her own meals.

D. Stay with the client during meals and for 1 hr afterward is correct. The nurse should offer
support and encouragement at mealtimes but also monitor the client's behavior to prevent
purging following food ingestion.
E. Offer specific privileges for sustained weight gain is correct. Positive reinforcement includes
rewards for improvements in eating behaviors and is an appropriate strategy for clients who have
eating disorders.
125. A nurse in a mental health clinic is assessing a client who was brought in by her adult
daughter stating that her mother has not been able to leave her home for weeks because she is
afraid to be outdoors alone. The nurse should anticipate planning care for managing which of the
following phobias?
A. Xenophobia
B. Acrophobia
C. Mysophobia
D. Agoraphobia
Answer: D. Agoraphobia
Rationale:
A. Xenophobia is a fear of strangers.
B. Acrophobia is a fear of heights.
C. Mysophobia is a fear of dirt or germs.
D. Agoraphobia is an irrational fear about being in places or circumstances where the client
would not have help in the event of panic or other forms of anxiety. Fear of being alone outdoors
is a common example.
126. A client who has major depressive disorder states to the nurse that he and his family would
be better off if he were gone. Which of the following is the nurse's priority response?
A. "Do you really think your family would be better off without you?"
B. "Are you thinking of harming yourself?"
C. "Tell me what is happening right now."
D. "When did you first start feeling this way?"
Answer: B. "Are you thinking of harming yourself?"

Rationale:
A. It is appropriate for the nurse to encourage a description of the client's perceptions, but this is
not the priority response at this time.
B. When a client expresses suicidal intent, it is the nurse's priority to determine the seriousness of
the client's intent, whether or not he has a plan and the means to follow through with it, and the
lethality of the means.
C. It is appropriate for the nurse to encourage a description of the client's perceptions, but this is
not the priority response at this time.
D. It is appropriate for the nurse to obtain a history of the client's current state, but this is not the
priority response at this time.
127. A nurse is admitting a client who has multiple injuries following a motor vehicle crash.
Shortly after admission, the client's partner arrives. He is distraught and blames himself for the
accident. Which of the following responses should the nurse make?
A. "Do not worry about that. Your wife will be fine."
B. "I think you should calm down a little before you see your partner."
C. "Why do you think the crash is your fault?"
D. "Tell me more about your feelings about what happened to your partner."
Answer: D. "Tell me more about your feelings about what happened to your partner."
Rationale:
A. This response illustrates the nontherapeutic communication technique of giving reassurance.
B. This response illustrates the nontherapeutic communication technique of giving advice.
C. This response illustrates the nontherapeutic communication technique of requesting an
explanation.
D. This response illustrates the therapeutic communication technique of exploring, and will
encourage the client to express his feelings about his partner's accident.
128. A nurse is caring for a client who has cancer and is scheduled for immediate chemotherapy.
The client tells the nurse that she wants to try nontraditional treatments first. Which of the
following responses should the nurse make?
A. "Using nontraditional treatments is not a good Idea. I'd rather you avoid that route."

B. "A lot of people think nontraditional treatments will work, and they find out too late that they
made the wrong choice."
C. "Your provider is very knowledgeable. If he prescribes chemotherapy, it's the best treatment
for you."
D. "Tell me more about your concerns about taking chemotherapy."
Answer: D. "Tell me more about your concerns about taking chemotherapy."
Rationale:
A. This response is an example of the nontherapeutic communication technique of disapproving.
B. This response is an example of the nontherapeutic communication technique of minimizing
the client's feelings. The client might also perceive a threat in the nurse's words.
C. This response is an example of the nontherapeutic communication technique of defending.
D. Asking the client to talk more about her fears and her concerns encourages communication. It
is an example of the therapeutic communication technique of exploring.
129. A nurse is caring for a 9-year-old boy who has a new diagnosis of diabetes mellitus and is
eager to return to school and participate in social events. The mother tells the nurse she is afraid
to let him take part in physical activities at school. Which of the following responses should the
nurse make?
A. "Tell me more about how you are feeling about your son's activities."
B. "You might want to use tutors to home-school him."
C. "I agree. His well-being is the most important."
D. "You sound overprotective. Let's talk about this some more."
Answer: A. "Tell me more about how you are feeling about your son's activities."
Rationale:
A. This response illustrates the therapeutic communication technique of exploring, and will
encourage the mother to express her feelings and fears about her son's disorder and exercise.
B. This response illustrates the nontherapeutic communication technique of giving premature
advice.
C. This response illustrates the nontherapeutic communication technique of giving approval or
agreement.

D. This response illustrates the nontherapeutic communication technique of making value
judgments.
130. A nurse is admitting an older adult client who has a suspected cognitive disorder. Which of
the following inventories should be included as part of the admission assessment?
A. Mental status examination (MSE)
B. Brief Patient Health Questionnaire (Brief PHQ)
C. Abnormal Involuntary Movements Scale (AIMS)
D. Scale for Assessment of Negative Symptoms (SANS)
Answer: A. Mental status examination (MSE)
Rationale:
A. The use of an MSE assists in identifying deterioration in mental status and brain damage,
which are findings associated with cognitive disorders.
B. The Brief PHQ is used as a screening tool to identify indications of depression in clients,
rather than a cognitive disorder.
C. The AIMS test is used to assess for tardive dyskinesia in clients taking antipsychotic
medications.
D. The SANS is used to assess for the presence of negative symptoms in clients who have
schizophrenia, rather than a cognitive disorder.
131. A nurse is caring for a client who has major depressive disorder. Which of the following
findings should the nurse expect?
A. A dismissal of past failures
B. Psychomotor agitation
C. An increase in energy
D. Sleep disturbances
Answer: D. Sleep disturbances
Rationale:
A. Clients who have depression often focus on perceived past failures and faults.
B. Psychomotor agitation is seen in clients who have bipolar disorder. Slowed body movement is
seen in clients with depression.

C. A lack of energy or passivity is seen in as many of 97% of clients with depression.
D. Sleep disturbances are common in clients with depression.
132. A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the
following findings should the nurse expect?
A. Hand tremors
B. Stuporous level of consciousness
C. Bradycardia
D. Hypotension
Answer: A. Hand tremors
Rationale:
A. Course tremors of the hands is an expected finding of alcohol withdrawal.
B. Stupor is an expected finding of alcohol intoxication rather than withdrawal.
C. Tachycardia, rather than bradycardia, is an expected finding of alcohol withdrawal.
D. Hypertension, rather than hypotension, is an expected finding of alcohol withdrawal.
133. A nurse in the emergency department is creating a plan of care for a client experiencing
alcohol intoxication. Which of the following interventions should the nurse plan to include?
(Select all that apply).
A. Contact the laboratory to obtain a blood sample.
B. Prepare the client for a CT scan.
C. Check the client’s pupil reactivity.
D. Obtain a urine specimen.
E. Perform a developmental screening test.
Answer: A. Contact the laboratory to obtain a blood sample.
B. Prepare the client for a CT scan.
C. Check the client’s pupil reactivity.
D. Obtain a urine specimen.
Rationale:
A. Contact the laboratory to obtain a blood sample is correct. A blood sample allows for a blood
alcohol level test to be performed.

B. Prepare the client for a CT scan is correct. A CT scan or other neurological tests is performed
to rule out brain injury or head trauma.
C. Check the clients pupil reactivity is correct. Checking for pupil reactivity provides
information about a clients neurological status.
D. Obtain a urine specimen is correct. A urine specimen is needed to perform a urine toxicology
screen.
E. Perform a developmental screening test is incorrect. A developmental screening test is
appropriate when needing information about a child or adolescents maturational or
developmental level.
134. A nurse is assessing a client who has a history of alcohol use disorder. Which of the
following questions should the nurse include to determine how the use of alcohol affects the
client’s psychosocial behaviors?
A. "Has alcohol use affected your performance at work?"
B. "Have you received prior treatment for substance use disorder?"
C. "Do you receive treatment for any mental health disorders?"
D. "At what age did you begin drinking alcohol?"
Answer: A. "Has alcohol use affected your performance at work?"
Rationale:
A. Inquiring about work performance is appropriate to include in a psychosocial assessment
related to substance use disorder.
B. Asking about prior treatment is appropriate for a substance use disorder history rather than a
psychosocial assessment.
C. Asking about treatment for mental health disorders is appropriate for a psychiatric history
rather than a psychosocial assessment.
D. Asking about the age the client began drinking is appropriate for a substance use disorder
history rather than a psychosocial assessment.
135. A nurse is caring for a child who has autism spectrum disorder. Which of the following
findings should the nurse expect? (Select all that apply).
A. Short attention span

B. Delayed language development
C. Spinning a toy repetitively
D. Ritualistic behavior
E. Consistent limit testing
Answer: B. Delayed language development
C. Spinning a toy repetitively
D. Ritualistic behavior
Rationale:
A. Short attention span is incorrect. A short attention span is an expected finding of attention
deficit hyperactivity disorder, rather than autism.
B. Delayed language development is correct. A delay in speech and language development is an
expected finding of autism.
C. Spins a toy repetitively is correct. Interest in repetitive activities is an expected finding of
autism.
D. Ritualistic behavior is correct. A need for routine and the presence of ritualistic behavior are
expected findings of autism.
E. Consistent limit testing is incorrect. Consistent limit testing is an expected finding of
oppositional defiant disorder, rather than autism.
136. A nurse in an emergency department is caring for a client who is experiencing acute alcohol
withdrawal. Which of the following actions should the nurse take first?
A. Implement seizure precautions.
B. Insert an IV access site.
C. Perform a neurological exam.
D. Obtain a blood specimen.
Answer: C. Perform a neurological exam.
Rationale:
A. Implementing seizure precautions is an appropriate intervention; however, there is another
intervention that the nurse should take first.
B. Initiating IV access is an appropriate intervention; however, there is another intervention that
the nurse should take first.

C. The first action the nurse should take when using the nursing process is assessment.
Performing a neurological exam is the priority intervention when using the assessment portion of
the nursing process to approach client care.
D. Obtaining a blood specimen is an appropriate intervention; however, there is another
intervention that the nurse should take first.
137. A nurse is teaching a community education course about the physical complications related
to substance use disorder. Which of the following findings should the nurse include in the
discussion as a health risk of heroin use?
A. Acute pancreatitis
B. Slowed breathing
C. Nasal septum perforation
D. Permanent short-term memory loss
Answer: B. Slowed breathing
Rationale:
A. Acute pancreatitis is a physical complication related to alcohol use disorder.
B. Slowed or arrested breathing is just one of the many physical complications related to heroin
use. Others include drowsiness, impaired coordination, nausea, and sedation.
C. Perforation of the nasal septum is a physical complication related to intranasal cocaine use.
D. Permanent short-term memory loss is a physical complication related to marijuana use.
138. A nurse is teaching a newly-admitted client about the possible physical effects of alcohol
withdrawal. Which of the following manifestations should the nurse include in the teaching?
(Select all that apply.)
A. Seizures
B. Illusions
C. Tremors
D. Polyphagia
E. Nystagmus
Answer: A. Seizures
B. Illusions

C. Tremors
Rationale:
A. Seizures is correct. Seizures are an expected finding of severe alcohol withdrawal.
B. Illusions is correct. Illusions are an expected finding of alcohol withdrawal.
C. Tremors is correct. Tremors are an expected finding of alcohol withdrawal.
D. Polyphagia is incorrect. Nausea and vomiting, rather than polyphagia, are expected findings
of alcohol withdrawal.
E. Nystagmus is incorrect. Nystagmus is an expected finding of alcohol intoxication rather than
alcohol withdrawal.
139. A nurse is teaching a community education course about the physical complications related
to substance use disorder. Which of the following findings should the nurse identify as the
primary cause of liver cirrhosis?
A. Alcohol
B. Caffeine
C. Cocaine
D. Inhalants
Answer: A. Alcohol
Rationale:
A. Chronic alcohol use disorder is one of the primary causes of cirrhosis of the liver.
B. Chronic ingestion of caffeine can result in many physical complications; however, it is not
associated with liver cirrhosis.
C. Cocaine can result in many physical complications; however, it is not associated with liver
cirrhosis.
D. Inhalants can result in many physical complications; however, they are not associated with
liver cirrhosis.
140. A charge nurse is discussing suicide interventions with nursing staff. Which of the following
should the nurse identify as an example of secondary intervention?
A. Providing support for family and friends following a suicide
B. Identifying individuals who are at higher risk for attempting suicide

C. Recognizing the warning signs of suicide
D. Performing life-saving measures following a suicide attempt
Answer: D. Performing life-saving measures following a suicide attempt
Rationale:
A. Providing support following a suicide is an example of tertiary intervention.
B. Identifying individuals at higher risk for suicide is an example of primary intervention.
C. Recognizing the warning signs of suicide is an example of primary intervention.
D. Care of the client during the actual suicide crisis, which includes performing life-saving
measures, is an example of secondary intervention.
141. A nurse is reinforcing teaching about alcohol tolerance with a newly admitted client. Which
of the following statements by the client indicates understanding?
A. "Alcohol tolerance produces physical changes when I haven’t recently ingested alcohol."
B. "Alcohol tolerance causes me to have an increased effect when taking opiates."
C. "I will develop a decreased physical response to alcohol."
D. "Alcohol tolerance is a medical emergency and can develop as a result of withdrawal."
Answer: C. "I will develop a decreased physical response to alcohol."
Rationale:
A. Alcohol withdrawal, rather than alcohol tolerance, produces physical changes when they no
longer have consistent alcohol levels in their system.
B. Alcohol tolerance can cause the client to develop a decreased response to opiates.
C. A client can develop alcohol tolerance due to repeated exposure to the substance and can have
a decreased physical response.
D. Alcohol withdrawal delirium is a medical emergency that can occur as a result of alcohol
withdrawal.
142. A nurse is providing teaching to a client who has alcohol use disorder about Alcoholics
Anonymous (AA). Which of the following client statements indicates an understanding of the
program’s basic concepts?
A. "I am responsible for my alcoholism."
B. "I need to identify things that cause me to be an alcoholic."

C. "I am powerless against my addiction to alcohol."
D. "I need to see a counselor who will be responsible for my recovery."
Answer: C. "I am powerless against my addiction to alcohol."
Rationale:
A. A basic concept of AA is that the client is not responsible for his addiction to alcohol.
B. A basic concept of AA is that the client cannot place blame on things or people for his
addiction to alcohol.
C. A basic concept of AA is that the client is powerless over his addiction to alcohol and
therefore needs assistance to overcome the addiction.
D. A basic concept of AA is that the client is responsible for his recovery.
143. A nurse is discussing comorbidities associated with eating disorders with a newly admitted
client. Which of the following conditions should the nurse include in the discussion? (Select all
that apply.)
A. Anxiety
B. Obsessive-compulsive disorder
C. Schizophrenia
D. Breathing-related sleep disorder
E. Depression
Answer: A. Anxiety
B. Obsessive-compulsive disorder
E. Depression
Rationale:
A. Anxiety is correct. Anxiety is a comorbid condition common in clients who have an eating
disorder.
B. Obsessive-compulsive disorder (OCD) is correct. OCD is a comorbid condition common in
clients who have an eating disorder, especially anorexia nervosa.
C. Schizophrenia is incorrect. Personality disorders, rather than schizophrenia, are comorbid
conditions common in clients who have an eating disorder.
D. Breathing-related sleep disorder is incorrect. Breathing-related sleep disorder is not a
comorbid condition associated with eating disorders.

E. Depression is correct. Depression is a comorbid condition common in clients who have an
eating disorder.
144. A nurse is caring for a client who has major depressive disorder (MDD). Which of the
following findings should the nurse expect?
A. Significant change in weight
B. Hyperexcitability
C. Exaggerated response to stimuli
D. Attention seeking behavior
Answer: A. Significant change in weight
Rationale:
A. A significant change in weight, either loss or gain, is an expected finding of MDD.
B. Lack of energy to respond to stimuli, rather than hyperexcitability, is an expected finding of
MDD.
C. Anhedonia, the inability to experience pleasure or respond appropriately to stimuli, is an
expected finding of MDD.
D. Attention seeking behavior is an expected finding of personality disorders, rather than MDD.
145. A nurse on a mental health unit is caring for clients who have various depressive disorders.
The nurse should identify which of the following client diagnoses as presenting the greatest risk
for suicide?
A. Premenstrual dysphoric disorder
B. Seasonal affective disorder
C. Major depressive disorder
D. Persistent depressive disorder
Answer: C. Major depressive disorder
Rationale:
A. All depressive disorders have a risk for suicide; however, premenstrual dysphoric disorder is
not the diagnosis with the greatest risk.
B. All depressive disorders have a risk for suicide; however, seasonal affective disorder is not the
diagnosis with the greatest risk.

C. A client who has major depressive disorder experiences periodic major depressive episodes
and is at greatest risk for suicide during these times.
D. All depressive disorders have a risk for suicide; however, persistent depressive disorder is not
the diagnosis with the greatest risk.
146. A nurse is caring for a new client who exhibits manifestations of a major depressive
episode. The provider states that she wants to rule out medical conditions which could also be
linked to the findings. The nurse should expect diagnostic testing for which of the following
medical conditions?
A. Pancreatitis
B. Cholecystitis
C. Tuberculosis
D. Hypothyroidism
Answer: D. Hypothyroidism
Rationale:
A. The expected findings of pancreatitis do not mimic those of a major depressive episode.
B. The expected findings of cholecystitis do not mimic those of a major depressive episode.
C. The expected findings of tuberculosis do not mimic those of a major depressive episode.
D. The expected findings of hypothyroidism, including changes in weight, sleep disturbances,
decreased energy, and changes in thought processes, mimic those of a major depressive episode.
147. A nurse on an acute mental health unit is caring for a client who has major depressive
disorder. Which of the following interventions is the nurse’s priority?
A. Monitor for risk of self-harm.
B. Administer prescribed antidepressants.
C. Encourage adequate fluid intake.
D. Assist with activities of daily living.
Answer: A. Monitor for risk of self-harm.
Rationale:
A. Self-harm or suicide presents the greatest risk to the client; therefore, monitoring for risk of
self-harm is the highest priority intervention.

B. Administering prescribed antidepressants is an appropriate intervention; however, it does not
address the greatest risk to the client and is therefore not the priority intervention.
C. Encouraging adequate fluid intake is an appropriate intervention; however, it does not address
the greatest risk to the client and is therefore not the priority intervention.
D. Assisting with activities of daily living is an appropriate intervention; however, it does not
address the greatest risk to the client and is therefore not the priority intervention.
148. A nurse is providing a community health education class about suicide prevention. Which of
the following should the nurse identify as risk factors for suicide? (Select all that apply).
A. Substance use disorder
B. Age greater than 45 years old
C. Female gender
D. Currently married
E. Schizophrenia
Answer: A. Substance use disorder
B. Age greater than 45 years old
E. Schizophrenia
Rationale:
A. Substance use disorder is correct. Clients who have a substance use disorder are at a higher
risk for suicide.
B. Age greater than 45 years old is correct. The rate of suicide increases with age and peaks after
the age of 45.
C. Female gender is incorrect. Males are more likely to commit suicide than females.
D. Currently married is incorrect. Clients who are married have a lower risk for suicide than
those who are divorced or single.
E. Schizophrenia is correct. Clients who have schizophrenia are at a high risk for suicide.
149. A nurse is caring for a client following a recent suicide attempt. Which of the following
actions should the nurse take?
A. Place metal utensils on the client’s meal tray.
B. Assign the client to a private room.

C. Inspect the client’s personal belongings.
D. Tuck bedcovers over client’s hands and arms.
Answer: C. Inspect the client’s personal belongings.
Rationale:
A. Clients should have plastic rather than metal utensils on the meal tray.
B. The client who is at risk for suicide should be in a semi-private room with the door open at all
times.
C. Inspecting the client and his personal belongings is an appropriate intervention to ensure that
the client does not have access to potentially harmful objects.
D. The client’s hands should be visible at all times and not under the bedcovers.
150. A charge nurse is providing teaching to a staff nurse about assisting the provider with
electroconvulsive therapy (ECT). Which of the following responses by the staff nurse indicates
understanding of the teaching?
A. "ECT is an effective treatment for personality disorders."
B. "I should monitor the client closely for hypotension following ECT."
C. "Informed consent should be obtained prior to ECT."
D. "It is a myth that clients experience seizures during ECT."
Answer: C. "Informed consent should be obtained prior to ECT."
Rationale:
A. ECT is effective in the treatment of depression rather than personality disorders.
B. The client is at risk for hypertension, rather than hypotension, following ECT.
C. ECT is a treatment that requires informed consent from the client or authorized person.
D. Clients experience induced seizures during ECT; however, the use of medications limits the
severity.
151. A nurse is caring for a client who has a new diagnosis of human immunodeficiency virus
(HIV). He states, “I don’t care what the doctors say, there is no way I can have HIV, and I don’t
need treatment for something I don’t have.” The nurse identifies that the client is experiencing
which of the following types of crisis?
A. Adventitious

B. Internal
C. Maturational
D. Situational
Answer: D. Situational
Rationale:
A. An adventitious crisis is one that is not a part of regular life such as a natural disaster or act of
terrorism.
B. An internal crisis is one that results from the inability to cope with life changes such as the
marriage of a child or age-related changes.
C. A maturational crisis is one that results from the inability to cope with life changes such as
moving away from home to go to college.
D. A diagnosis of HIV is a situational crisis which is one that is unexpected but is part of regular
life such as a serious illness or financial loss.
152. A charge nurse is conducting a staff education in-service about depressive disorders. Which
of the following should the nurse identify as a risk factor for depression?
A. Being married
B. Pregnancy
C. Male gender
D. Chronic illness
Answer: D. Chronic illness
Rationale:
A. Being unmarried, rather than married, is a primary risk factor for depression.
B. The postpartum period, rather than the pregnancy, is a primary risk factor for depression.
C. Being female, rather than male, is a primary risk factor for depression.
D. Having a medical illness, especially one that is chronic, is a primary risk factor for depression.
153. A nurse is discussing ageism with a newly licensed nurse. Which of the following
statements by the newly licensed nurse indicates an understanding of the concept?
A. "Ageism refers to a higher level of respect that Eastern cultures give to their elders."
B. "Ageism refers to the stereotype that older adults are not able to understand new information."

C. "Ageism refers to assumptions about an older adult client based on gender and economic
status."
D. "Ageism refers to the increase in physical care required by older adults."
Answer: B. "Ageism refers to the stereotype that older adults are not able to understand new
information."
Rationale:
A. Ageism results in a decrease in respect for older adults and is more common in Western
cultures.
B. Ageism refers to stereotypes about older adults based solely on age. The belief that older
adults are unable to learn and understand new information is a myth of ageing.
C. Ageism is based solely on age rather than gender or economic status.
D. Ageism is a bias against older adults solely based on age. Caregiver burden is a common
result of the increase in physical care required by older adults.
154. A nurse is caring for a 48-year-old client who is grieving following the death of her husband
seven months ago. The client reports that she has lost 30 lb, and is having difficulty sleeping.
Which of the following factors indicate the client is experiencing maladaptive grieving?
A. The client is 48 years old.
B. The client’s husband died seven months ago.
C. The client has lost 30 lb.
D. The client is having difficulty sleeping.
Answer: B. The client’s husband died seven months ago.
Rationale:
A. Clients of all ages can experience maladaptive grieving; therefore, the client’s age does not
indicate this form of grief.
B. One of the defining factors of maladaptive grieving is grief that lasts 6 months or longer after
the loss.
C. Weight loss is a common finding of the expected grief process and this finding alone does not
indicate maladaptive grieving.
D. Insomnia is a common finding of the expected grief process and this finding alone does not
indicate maladaptive grieving.

155. A nurse is caring for a client who has a depressive disorder. The client states, “I just can’t
feel any happiness or joy in life.” Which of the following terms should the nurse use when
documenting this finding?
A. Anhedonia
B. Anergia
C. Anosognosia
D. Akathisia
Answer: A. Anhedonia
Rationale:
A. Anhedonia refers to the client’s inability to experience pleasure or joy.
B. Anergia refers to a client’s lack of energy.
C. Anosognosia refers to the inability to recognize one’s illness.
D. Akathisia refers to repetitive movements, such as pacing or fidgeting, commonly associated
with antipsychotic medications.
156. A nurse in a mental health clinic is discussing guided imagery with a newly licensed nurse.
Which of the following clients should the nurse suggest offering the therapy to?
A. Post-traumatic Stress Disorder
B. Schizophrenia
C. Pedophilia
D. Paranoid personality disorder
Answer: A. Post-traumatic Stress Disorder
Rationale:
A. Guided imagery is a recommended treatment to relieve the anxiety associated with posttraumatic stress disorder. It is a complementary alternative therapy also used to treat sleep
disorders, anxiety, and pain.
B. Guided imagery is not indicated for the treatment of schizophrenia.
C. Guided imagery is not indicated for the treatment of pedophilia.
D. Guided imagery is not indicated for the treatment of paranoid personality disorder.

157. A nurse is caring for a client who has bipolar disorder. The client states, “I feel like
Superman. I can do anything. I can fly home today and then become a U.S. Senator.” Which of
the following findings is this client exhibiting?
A. Flight of ideas
B. Grandiosity
C. Reality testing
D. Derealization
Answer: B. Grandiosity
Rationale:
A. Flight of ideas refers to continuous, rapid speech which abruptly changes from topic to topic.
B. Grandiosity refers to the client’s belief that he has special abilities or great powers.
C. Reality testing refers to the client’s ability to recognize and correct alterations in thinking.
D. Derealization refers to the client’s belief that the environment is unreal or distant.
158. A nurse is assessing a client who has a mood disorder to determine his readiness for
discharge. Which of the following statements by the client indicates he is ready for discharge?
A. "Right now, I can’t bathe or dress myself, but that’s not important."
B. "When I get home, I’m going to let the people who put me here know how I angry I am."
C. "I will take my medicines as I should and know to call the number you gave me if I have bad
thoughts."
D. "Taking care of myself is important, but it’s okay if I want to take a break and not do
anything."
Answer: C. "I will take my medicines as I should and know to call the number you gave me if I
have bad thoughts."
Rationale:
A. This statement identifies an inability to perform activities of daily living, which does not
support readiness for discharge.
B. This statement identifies a lack of progress toward improved interpersonal functioning and
judgment, which does not support readiness for discharge.
C. This statement verbalizes a willingness to adhere to a medication regimen and a plan for help
to avert future crises, both of which support the client’s readiness for discharge.

D. This statement identifies a lack of understanding of the importance of self-care and assuming
responsibility, which does not support readiness for discharge.
159. A nurse is caring for a client who has bipolar disorder and is running around the unit asking
people to dance with her. Which of the following interventions should the nurse take?
A. Turn on a dance video so the client can burn off excess energy.
B. Offer the client a low-calorie snack in return for stopping the behavior.
C. Take the client outside and sit with her in the garden area.
D. Observe the client closely for the development of aggressive behavior.
Answer: C. Take the client outside and sit with her in the garden area.
Rationale:
A. Constant activity during mania can result in exhaustion; therefore, the nurse should not
promote further activity.
B. The nurse should use step-by-step instructions and limit setting rather than offering choices.
The nurse should also offer frequent high-calorie fluids to replenish burned calories and prevent
dehydration.
C. It is appropriate to remove the client from the stimulating environment and to use instruction,
rather than bargaining, to decrease the activity level. Additionally, the nurse’s presence provides
security and support to the client.
D. This intervention does not address the client’s risk for physical exhaustion.
160. A nurse in a mental health clinic is conducting a staff education session on schizophrenia.
Which of the following manifestations should the nurse identify as negative symptoms? (Select
all that apply.)
A. Delusions
B. Hallucinations
C. Anhedonia
D. Poor judgment
E. Blunt affect
Answer: C. Anhedonia
E. Blunt affect

Rationale:
A. Delusions is incorrect. Delusions are an example of a positive symptom of schizophrenia.
B. Hallucinations is incorrect. Hallucinations are an example of a positive symptom of
schizophrenia.
C. Anhedonia is correct. Anhedonia is an example of a negative symptom of schizophrenia. Poor
judgment is incorrect.
D. Poor judgment is an example of a cognitive symptom of schizophrenia.
E. Blunt affect is correct. Blunt affect is an example of a negative symptom of schizophrenia.
161. A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The
client’s parents are tearful and express feelings of guilt. Which of the following statements
should the nurse make?
A. "You said that you feel guilty about your daughter’s diagnosis. Let’s talk about what is
causing you to feel this way."
B. "You should not feel guilty about your daughter’s diagnosis. Schizophrenia is unpreventable."
C. "I’m sure your daughter’s diagnosis is very difficult to deal with, but everything will be all
right once she receives the proper treatment."
D. "Your provider has explained the causes of schizophrenia. Why do you feel guilty about your
daughter's diagnosis?"
Answer: A. "You said that you feel guilty about your daughter’s diagnosis. Let’s talk about what
is causing you to feel this way."
Rationale:
A. This statement is an example of clarification and promotes further discussion, which is a
therapeutic communication technique.
B. This statement provides personal opinion and false information, both of which are
nontherapeutic communication techniques.
C. This statement provides false reassurance which is a nontherapeutic communication
technique.
D. This statement uses a “why” question to ask for an explanation, which is a nontherapeutic
communication technique.

162. A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the
following statements should the nurse make?
A. "You should be aware that excessive sleeping is an early sign of relapse."
B. "Relapse is an indication that you are not taking your medications properly."
C. "You should keep your provider’s and therapist’s number with you."
D. "Taking an additional dose of medication is appropriate as soon as signs of relapse appear."
Answer: C. "You should keep your provider’s and therapist’s number with you."
Rationale:
A. Difficulty sleeping, rather than excessive sleeping is an early sign of relapse.
B. Relapse can occur for several reasons and does not indicate failure on the client’s part.
C. The client should have a written plan, including important numbers, available at all times in
case relapse occurs.
D. The client should not change the dosage of medication without a prescription from the
provider.
163. A nurse is caring for a client who has schizophrenia. The client states, “The government is
forcing thoughts into my brain through satellites.” The nurse should document that the client is
experiencing which of the following types of delusions?
A. Persecution
B. Control
C. Erotomanic
D. Somatic
Answer: B. Control
Rationale:
A. A client who is experiencing a persecution delusion believes that others are trying to harm
him.
B. A client who is experiencing a control delusion believes that others are trying to control him;
this is often believed to be by forcing thoughts into the brain.
C. A client who is experiencing an erotomanic delusion believes that someone desires a romantic
relationship with him.

D. A client who is experiencing a somatic delusion believes that his body is undergoing unusual
or unnatural changes.
164. A nurse is caring for a client who has schizophrenia and is experiencing a hallucination.
Which of the following actions should the nurse take?
A. Act to the client as if the hallucination is real.
B. Instruct the client to argue with the voices that are a part of the hallucination.
C. Ask the client direct questions about the hallucination.
D. Tell the client that the hallucination is not a part of reality.
Answer: C. Ask the client direct questions about the hallucination.
Rationale:
A. Acting as if the hallucination real will increase the client’s difficulty in identifying reality and
is therefore not an action the nurse should take.
B. Arguing will increase the client’s anxiety level and is therefore not an action the nurse should
take.
C. Asking the client direct questions about the hallucination provides important data to identify
the client’s risk level and current mental status.
D. Telling the client that the hallucination is not real will increase the client’s anxiety level and is
therefore not an action the nurse should take.
165. A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the
following characteristics are expected findings of OCD? (Select all that apply.)
A. Difficulty relaxing
B. Irrational fear of certain objects
C. Rule-conscious behavior
D. Unaware of compulsions
E. Perfectionist behavior
Answer: A. Difficulty relaxing
C. Rule-conscious behavior
E. Perfectionist behavior
Rationale:

A. Difficulty relaxing is correct. OCD causes high levels of stress and anxiety resulting in the
client having difficulty relaxing.
B. Irrational fear of certain objects is incorrect. Phobias, rather than OCD, result in extreme and
irrational fears.
C. Rule-conscious behavior is correct. Clients who have OCD have increased anxiety if rules are
not followed.
D. Unaware of compulsions is incorrect. Clients who have OCD are aware of compulsions which
results in increased anxiety.
E. Perfectionist behavior is correct. Clients who have OCD strive for perfection and have
increased anxiety if it is not attained.
166. A nurse is planning discharge for a client who has borderline personality disorder. Which of
the following interventions should be included for this client?
A. Dialectical behavior therapy
B. Behavioral contract
C. Bibliotherapy
D. Safety plan
Answer: A. Dialectical behavior therapy
Rationale:
A. Dialectical behavior therapy is appropriate for the treatment of clients with borderline
personality disorder and is often a part of the discharge plan.
B. A behavior contract is appropriate for a client who has aggressive or disruptive behavior rather
than borderline personality disorder.
C. Bibliotherapy is appropriate for clients who need to gain skills for dealing with stressful
situation rather than a client who has borderline personality disorder.
D. A safety plan is appropriate for a competent adult client who is in an abusive relationship
rather than for a client who has borderline personality disorder.
167. A nurse is caring for a client who is receiving treatment for alcohol withdrawal. Which of
the following findings is the highest priority?
A. Vitamin deficiency

B. Diaphoresis
C. Tremors
D. Illusions
Answer: D. Illusions
Rationale:
A. Vitamin deficiency is a finding that can occur during alcohol withdrawal; however, it does not
present the greatest risk to the client and is therefore not the priority finding.
B. Diaphoresis is a finding that can occur during severe alcohol withdrawal; however, it does not
present the greatest risk to the client and is therefore not the priority finding.
C. Tremors are a finding that can occur during mild to moderate alcohol withdrawal; however,
tremors do not present the greatest risk to the client and are therefore not the priority finding.
D. Illusions may occur during severe alcohol withdrawal and prevent the greatest safety risk to
the client, and are therefore the priority finding.
168. A nurse in a long-term care facility is caring for a client who has Alzheimer’s disease.
Which of the following actions should the nurse include in the plan of care?
A. Post a written schedule of daily activities.
B. Use an overhead loudspeaker to announce events.
C. Provide a consistent daily routine.
D. Allow the client to choose free-time activities.
Answer: C. Provide a consistent daily routine.
Rationale:
A. Picture symbols, rather than written schedules, are appropriate for the care of a client who has
Alzheimer’s disease.
B. Personal communication with a low voice, rather than a loudspeaker, is appropriate for the
care of a client who has Alzheimer’s disease.
C. A consistent daily routine is appropriate for the care of a client who has Alzheimer’s disease.
D. Providing the client with choices can increase client anxiety and is therefore not appropriate
for the care of a client who has Alzheimer’s disease.

169. A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted,
superficial cuts going up and down his right arm. Which of the following actions should the
nurse take first?
A. Implement the client’s behavioral modification plan.
B. Document the size and location of the cuts.
C. Inspect the cuts for debris.
D. Administer a tetanus antitoxin.
Answer: C. Inspect the cuts for debris.
Rationale:
A. The nurse should implement a behavioral modification plan to prevent this self-destructive
behavior; however, there is another action the nurse should take first.
B. The nurse should document information about the cuts to record the incident; however, there
is another action the nurse should take first.
C. The first action the nurse should take when using the nursing process is to assess the client,
therefore inspecting the cuts is the first action the nurse should take.
D. The nurse should administer a tetanus injection to the client to prevent the occurrence of
infection; however, there is another action the nurse should take first.
170. A nurse is caring for an adolescent client who has conduct disorder. The client reports that
she has received five speeding tickets in the past 6 months. Which of the following interventions
should the nurse take?
A. Make a contract with the client not to drive over the speed limit.
B. Call the local police and alert them to the client’s car license plate number and the make and
model of her car.
C. Ask the client to “hand over the keys” to you, and tell her that now she must use a cab or other
public transportation until your next session.
D. Inform the client that she cannot drink and drive.
Answer: A. Make a contract with the client not to drive over the speed limit.
Rationale:
A. A behavior contract is appropriate to identify the expected behavior and consequences. The
client, by signing the contract, assumes responsibility for her behavior.

B. Contacting authorities is a breach of client confidentiality.
C. The nurse does not have the legal authority to take the client’s keys.
D. This action does not address the client’s present concerns and behaviors.
171. A nurse on an acute mental health unit is caring for a group of clients. For which of the
following clients is seclusion contraindicated?
A. An adult client following a suicide attempt
B. A school-age client who attempts to repeatedly bite staff
C. An adolescent client who throws objects at other clients
D. An older adult client who is manic and crying due to overstimulation
Answer: A. An adult client following a suicide attempt
Rationale:
A. Seclusion is contraindicated for a client who has suicidal tendencies due to the need for direct
and constant observation.
B. Seclusion is appropriate for a client who displays behavior that is harmful to others.
C. Seclusion is appropriate for a client who displays behavior that is harmful to others.
D. Seclusion is appropriate for a client who demonstrates a need for a decrease in sensory
stimulation.
172. A nurse manager is providing staff education about working with clients who have a history
of anger and aggression. Which of the following information should the nurse include in the
teaching? (Select all that apply.)
A. Avoid wearing necklaces during client care.
B. Know the layout of the facility.
C. Stand directly in front of the client when talking.
D. Bring security with you for all client interactions.
E. Provide immediate verbal feedback for escalating behavior.
Answer: A. Avoid wearing necklaces during client care.
B. Know the layout of the facility.
E. Provide immediate verbal feedback for escalating behavior.
Rationale:

A. Avoid wearing necklaces during client care is correct. Necklaces or any dangling jewelry
present a safety hazard when working with angry or aggressive clients.
B. Know the layout of the facility is correct. Knowing the layout of the unit is a safety
consideration that can reduce the risk for injury when working with an angry or aggressive client.
C. Stand directly in front of the client when talking is incorrect. Standing directly in front of the
client can be interpreted as confrontational by an angry or aggressive client.
D. Bring security with you for all client interactions is incorrect. The presence of security can
escalate agitation in an angry or aggressive client; therefore, security should remain in the
background and should only be used if needed.
E. Provide immediate verbal feedback for escalating behavior is correct. Providing immediate
verbal feedback for escalating behavior is an effective de-escalation technique.
173. A nurse enters the room of a client who becomes verbally abusive. Which of the following
actions should the nurse take?
A. Inform the client of consequences.
B. Speak slowly in a low, calm voice.
C. Forbid the client from speaking in an abusive manner.
D. Remain a distance of 1 ft away from the client.
Answer: B. Speak slowly in a low, calm voice.
Rationale:
A. Providing a response that can be interpreted as punitive or threatening can escalate the
behavior.
B. Speaking in this manner conveys to the client that the nurse is controlled, nonthreatening, and
caring.
C. Speaking in an abusive manner may be the only way the client can express his feelings.
Forbidding communication may cause an escalation of the angry behavior.
D. The nurse should stay about 1 ft farther than the client can reach with his arms or legs to
provide safety and to give the client enough personal space.

174. A home health nurse drives up to the house of her client, who has schizophrenia with manic
episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the
following actions should the nurse take?
A. Honk the car horn to get the client’s attention.
B. Calmly speak the client’s name out of the car window.
C. Keep driving in a path that is going away from the client’s house.
D. Stop the car in the client’s driveway and call the authorities.
Answer: C. Keep driving in a path that is going away from the client’s house.
Rationale:
A. This action draws the client’s attention to the nurse and increases the risk for injury.
B. This action draws the client’s attention to the nurse and increases the risk for injury.
C. This is an appropriate action for the nurse to take as it removes her from immediate danger.
D. While it is appropriate to contact the authorities this action places the nurse at risk for injury.
175. A nurse in a mental health facility is interacting with a client who is angry and becoming
increasingly aggressive. Which of the following actions should the nurse take?
A. Move the client to a private area so the conversation will not be disturbed.
B. Use clarification to determine what the client is feeling.
C. Speak to the client using an authoritative voice.
D. Maintain constant eye contact with the client.
Answer: B. Use clarification to determine what the client is feeling.
Rationale:
A. The nurse should use caution and converse with the client in an area that is visible to other
staff members.
B. The nurse should use clarification to ensure the client knows his feelings are heard and
understood. Clarification can make the client feel less vulnerable and enable the client to channel
anger in a less threatening manner.
C. The nurse should speak to the client who displays anger in a voice that is soft, low, and
calming.
D. The nurse should allow for breaks in eye contact with the client, as staring can be interpreted
as threatening.

176. A nurse in an emergency department is performing an assessment on a client who reports
being sexually assaulted. Which of the following actions should the nurse take first?
A. Ask the client for permission to take photographs.
B. Document the client's verbatim statements.
C. Provide community sexual assault support contacts.
D. Determine any physical signs of injury.
Answer: B. Document the client's verbatim statements.
Rationale:
A. After documenting the client's verbatim statements, the nurse should assess the client for signs
of physical trauma. This assessment should include a pre-printed body map and photographs of
injuries. The nurse should obtain the client's permission prior to taking photographs.
B. The first action the nurse should take is to document the client's actual statements.
C. Providing support contact information is the final action the nurse should take after
documenting the client's statements and assessing and documenting physical injury.
D. After documenting the client's verbatim statements, the nurse should assess the client for signs
of physical trauma.
177. A nurse is caring for an older adult client whose provider will discharge him to an extendedcare nursing facility the following morning. The client asks the nurse why he has to go to "that
place." Which of the following responses should the nurse make?
A. "Your doctor feels that this is the best place for you right now."
B. "Why don't you ask your doctor about that when she comes in to see you?"
C. "Did your doctor or anyone else talk to you about going to the nursing home?"
D. "Your family can't take care of you at home, so you will need to go there."
Answer: C. "Did your doctor or anyone else talk to you about going to the nursing home?"
Rationale:
A. This response is nontherapeutic because it dismisses the client's concerns and impedes further
communication.
B. By referring the client to another member of the team, the nurse implies that she is not willing
or able to help him with his concerns.

C. It is important to identify what the client thinks he has heard about his discharge. Clarification
of information can proceed after this.
D. Even if this is true, this response does not allow the client to verbalize his fears or concerns
and impedes further communication.
178. A client who has coronary artery disease tells the nurse he is afraid of dying from a heart
attack. Which of the following responses should the nurse make?
A. “Perhaps you should discuss this with your physician.”
B. “Of course you aren’t going to die, at least not in the immediate future.”
C. “I recommend you exercise daily and avoid smoking to decrease your risk.”
D. “Tell me more about these fears of dying from a heart attack.”
Answer: D. “Tell me more about these fears of dying from a heart attack.”
Rationale:
A. With this response, the subject is changed and the client is encouraged to stop sharing feelings
with the nurse.
B. With this response, the nurse gives the client false reassurance which belittles the client and
may stop him from sharing his feelings.
C. This response gives premature advice, which inhibits problem solving by the client and
conveys that the nurse knows what is best.
D. With this response, the nurse uses the therapeutic communication technique of exploring to
encourage further communication about the client’s feelings.
179. A school nurse is speaking to the mother of a 16 year old male adolescent. The mother has
concerns about her son. Which of the following statements by the mother should indicate to the
nurse that the adolescent is at risk for suicide?
A. "His favorite teacher committed suicide a few weeks ago."
B. "He has slept 9 hours each night for the past 2 years."
C. "He is very religious and attends services twice a week."
D. "He spends much of his time with his two school friends."
Answer: A. "His favorite teacher committed suicide a few weeks ago."
Rationale:

A. Adolescents are at risk for a "copycat" suicide if a peer or a significant role model has recently
committed suicide. Adolescents often act impulsively and can be easily frustrated. The fact that
an admired person committed suicide is a stressor that could put the adolescent at risk for
suicide.
B. A change in sleep habits or the presence of insomnia are manifestations of depression, which
would increase the risk for suicide.
C. Having a religious affiliation is a protective factor against suicide.
D. Having the social support of friends is a protective factor against suicide. The information that
he has friends with whom he spends time means that the adolescent is not completely isolated
from others. A lack of social support is a risk factor for suicide.
180. A home health nurse is speaking to a group of acute care nurses about domestic violence.
Which of the following statements by one of the acute care nurses indicates a need for
clarification?
A. "I have heard that abusers try to keep their partner isolated from others."
B. "I know that abusers lack social supports and social skills."
C. "I know that men who are abusers gain power through intimidation."
D. "I have heard that abusers think of themselves as important and have high self-esteem."
Answer: D. "I have heard that abusers think of themselves as important and have high selfesteem."
Rationale:
A. A typical victimizer is very possessive and attempts to keep the partner isolated from friends
and family.
B. A typical victimizer has few social supports and may lack social skills.
C. A typical victimizer gains power and control by intimidating his victim.
D. Victimizers typically have low self-esteem and diminished feelings of self-worth. They may
show a different type of personality to the community than the one shown to the partner.
181. A home health care nurse is visiting an older adult client who tells the nurse that she is
feeling tired, is unable to shop for groceries, and would like the nurse to shop for her. Shopping

and performing personal errands for the client is prohibited in the nurse’s job description. Which
of the following is an appropriate nursing response?
A. "I won’t be able to shop for you today because I have to get home to my family."
B. "I would be happy to do whatever I can to help you."
C. "What I think you should do is wait for the days when you feel better and do your grocery
shopping then."
D. "Let’s look at some other resources to solve this problem."
Answer: D. "Let’s look at some other resources to solve this problem."
Rationale:
A. This response may or may not be true, but it leaves the client with no solution to her problem
and is not an honest reason for the nurse to refuse this task. A therapeutic nursing relationship
should be honest and genuine.
B. This response implies that the nurse will buy the groceries for the client. This is a professional
boundary issue since providing personal errands is forbidden in the nurse’s job description.
C. This response is an example of the nontherapeutic communication technique of giving advice.
It implies that the client is incapable of considering that obvious option and that the nurse
"knows best."
D. Acknowledging that the client needs assistance on certain days and encouraging the
formulation of an action plan regarding community resources for that problem is an appropriate
nursing response. The nurse should work within her job description and collaborate with others,
making appropriate referrals within the community.
182. A nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. The
client tells the nurse that she is scared and wishes she had never smoked. Which of the following
responses should the nurse make?
A. "It’s okay to feel scared. Let’s talk about what you are afraid of."
B. "Don’t worry. The important thing is you have now quit smoking."
C. "I understand your fears. I was a smoker also."
D. "Your doctor is a great surgeon. You will be fine."
Answer: A. "It’s okay to feel scared. Let’s talk about what you are afraid of."
Rationale:

A. It is the nurse’s responsibility to acknowledge the client’s statement, to encourage
verbalization, and to explore the client’s feelings.
B. By telling the client not to worry because she has quit smoking, the nurse gives false
reassurance and approval. This minimizes the client’s feelings and concerns.
C. Telling the client that the nurse understands the fears and disclosing personal information
about smoking is inappropriate, since the nurse has not asked the client about her fears. In
addition, it is inappropriate to disclose personal information to the client.
D. Telling the client that she will be fine is false reassurance and it demeans the client’s concerns.
183. A nurse is making a home visit for a 16-year old adolescent who attempted suicide. Which
of the following behaviors should alert the nurse that the adolescent still has suicidal intent?
A. Telling his parents that he doesn’t want to talk about the suicide attempt.
B. Stating that he wants to be with his peers more than with his parents.
C. Preferring to eat his meals while watching TV.
D. Planning to give his CD collection to his girlfriend.
Answer: D. Planning to give his CD collection to his girlfriend.
Rationale:
A. A 16-year old adolescent normally tends to be introspective and may be unwilling to discuss
feelings with adults, but this is not a risk factor for suicide.
B. Acceptance by peers is very important for adolescents. Detachment from parents is normal for
this age group and is not a risk factor for suicide.
C. A refusal to eat or other dramatic change in appetite is a sign of increasing depression which
can increase the risk for suicide.
D. Warning signs of suicide include giving away possessions the person cherishes, talking about
his own death, and describing himself as worthless.
184. A client at 36 weeks gestation has just delivered a stillborn baby. Which of the following
statement should the nurse make?
A. "I understand your grief. I lost a baby also."
B. "You may hold your baby as long as you want."
C. "I have called for the chaplain to come and stay with you."

D. "This is for the best. Your baby was very ill."
Answer: B. "You may hold your baby as long as you want."
Rationale:
A. This is not the time to share personal losses with the client or to presume that because the
nurse had a loss she can understand the client’s loss.
B. Holding the newborn is essential because it helps the client confront the reality of the loss and
facilitates progression through the grief process.
C. The nurse should not presume to call in support persons, such as the chaplain, without
permission of the client.
D. Telling the client that this was for the best ignores the client’s feelings and is likely to stifle
further conversation with the client.
185. A client who is about to undergo abdominal surgery states that he is very anxious about the
operation. Which of the following responses should the nurse make?
A. Ask him to describe what he is feeling.
B. Give the client some reading material as a distraction.
C. Suggest that he take a walk around the unit.
D. Refer him to the pastoral care team.
Answer: A. Ask him to describe what he is feeling.
Rationale:
A. This response encourages verbalization and exploration of the client’s feelings. The nurse
should stay with a client who is anxious, should collect data about the client’s anxiety level, and
should explore the client’s feelings.
B. Although distraction can sometimes decrease mild anxiety, by giving the client reading
material the nurse is ignoring and minimizing the client’s concerns. In addition, if the client has
severe anxiety, he will be unable to focus on distractions.
C. Although exercise can sometimes decrease mild anxiety, by suggesting that the client take a
walk around the unit the nurse is ignoring the client’s concerns.
D. A referral to another team member sends the message that the nurse does not wish to discuss
the client’s statement.

186. A nurse in an acute care mental health facility is admitting a client who reports feeling
depressed, sad, moody, and overly anxious. Which of the following is the nurse’s assessment
priority?
A. Coping abilities
B. Support systems
C. Suicide risk
D. Psychiatric history
Answer: C. Suicide risk
Rationale:
A. It is important to explore the client’s coping abilities, but another assessment is the priority.
B. It is important to explore the client’s support systems, but another assessment is the priority.
C. The greatest risk to the safety of a client is self-harm. Therefore, the priority for the nurse to
determine is the client’s thoughts or plans suicide.
D. It is important to document the client’s psychiatric history, but another assessment is the
priority.
187. A nurse in an acute care facility is admitting an older adult client who has dementia due to
Alzheimer’s disease. The nurse notes that the client’s partner appears exhausted. He states that he
is finding it more and more difficult to care for his wife. Which of the following interventions is
the nurse’s priority?
A. Recommend that the partner place the client in a long-term care facility.
B. Suggest that the partner see a counselor to help him cope with his exhaustion.
C. Ask the partner to talk about his difficulties in caring for the client.
D. Tell the partner to call a family meeting to get help.
Answer: C. Ask the partner to talk about his difficulties in caring for the client.
Rationale:
A. The criteria for admission to long-term care address the client’s needs and the level of
assistance she requires. This might be an appropriate intervention, but another intervention is the
priority.
B. Suggesting that the partner talk to a counselor could help him to cope with his exhaustion, but
another action is the priority.

C. The first action the nurse should take using the nursing process priority framework is to assess
the partner’s difficulties in caring for his wife.
D. Calling a family meeting might be appropriate in order to obtain assistance for the partner and
to make plans for the client’s future care, but another action is the priority.
188. A nurse in an emergency department is assessing a client who has traumatic injuries
following an assault. The client sits quietly and calmly in the examination room and states, "I’m
fine." The nurse should recognize the client’s behavior as which of the following reactions?
A. Denial
B. Displacement
C. Projection
D. Undoing
Answer: A. Denial
Rationale:
A. Denial is a defensive coping mechanism that protects the client from increasing anxiety
levels. The client consciously disowns intolerable thoughts and ideas. It is a common response of
victims of violent crimes.
B. With displacement, the client transfers emotions from one situation to another.
C. With projection, the client attributes her own feelings to another person.
D. With undoing, the client tries to make amends for something she has done.
189. A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a
client. Which of the following actions should the nurse take?
A. Set limits for the relationship
B. Promote the use of transference by the client
C. Instruct the client on how he should behave.
D. Engage in friendly interactions with the client.
Answer: A. Set limits for the relationship
Rationale:
A. The nurse should set professional boundaries with the client through limit setting regarding
when and where to meet, roles of the relationship, personal space, and other parameters.

B. Transference is the displacement of the client’s feelings about a significant person to the
nurse. The nurse should not promote transference because it can interfere with the therapeutic
relationship.
C. Instructing the client on how he should behave does not foster trust in the nurse-client
relationship and may promote negative client behavior. The nurse should help the client enhance
his own problem solving skills and should foster independence, but should avoid giving advice
on how to behave.
D. Engaging in a friendly relationship meets the needs of both parties in a social relationship. In
a therapeutic nurse-client relationship, the goal is to meet client needs through use of problemsolving and therapeutic communication. A social relationship encourages blurring of boundaries
and is not part of the professional nurse-client relationship.
190. A nurse in a mental health facility is preparing to interview a client who is has
schizophrenia. Which of the following actions should the nurse take?
A. Sit on the other side of a table from the client.
B. Place the client in a chair higher than the nurse.
C. Start the interview with a question the client can answer with a "yes" or "no."
D. Sit beside the client rather than facing him.
Answer: C. Start the interview with a question the client can answer with a "yes" or "no."
Rationale:
A. The nurse should try to prevent placing a table or desk between herself and the client because
that can be a barrier to open communication.
B. The nurse and client should be sitting at approximately the same height to increase the client’s
comfort and to facilitate open communication during the interview. If the client is only
comfortable to talk while standing, the nurse should stand also so that they are on the same
approximate level.
C. The nurse should begin the interview with an open-ended question or statement to encourage
the client to talk.
D. The nurse should sit beside the client or at a 90? angle from him so that direct eye contact is
unnecessary. Sitting facing the client directly can cause him to feel uncomfortable and can make
the interview more intense.

191. A nurse in an acute care mental health facility is sitting with a client who has schizophrenia.
The client whispers to the nurse, “I’m being kept in this prison against my will. Please try to get
me out.” Which of the following responses should the nurse make?
A. "Why do feel that you need to leave?"
B. "You feel that you don’t belong here?"
C. "We are here to help you and give you the care that you need right now."
D. "Try to take some deep breaths and I’m sure you’ll feel better."
Answer: B. "You feel that you don’t belong here?"
Rationale:
A. Asking a "why" question implies criticism of the client’s statement and can cause the client to
feel defensive.
B. Restating is a therapeutic communication technique and encourages further dialogue.
C. Trying to convince the patient to accept treatment can cause a debate between the nurse and
client regarding the client’s delusion that she is being imprisoned at the facility.
D. By telling the client that taking deep breaths will help her feel better the nurse is changing the
subject and providing false reassurance, which minimizes the client’s feelings.
192. A nurse is sitting in the day room at an acute care mental health facility with a group of
clients who are watching television. Suddenly one of the clients jumps up screaming and runs out
of the room. Which of the following actions should the nurse take?
A. Ask the group what they think about the client’s behavior.
B. Follow the client to determine the cause of the behavior.
C. Ignore the incident because it is an attention-seeking behavior.
D. Stay with the group and ask another client to go and check on the situation.
Answer: B. Follow the client to determine the cause of the behavior.
Rationale:
A. Because of client confidentiality, the nurse should not ask the group what they think about
another client’s behavior.
B. The nurse should find the client to determine if immediate intervention is necessary to address
potential risk to the client or others. A change in behavior (such as becoming loud or

demonstrating hyperactive behavior) may precede aggressive or violent acts toward self or
others. The nurse should find the client to determine if immediate intervention is necessary to
address potential risk to the client or others.
C. Ignoring the incident does not address the potential risk to the client. The nurse should not
presume that this was attention-seeking behavior.
D. Sending another client to check on the situation does not allow the nurse to determine if
immediate intervention is necessary and places both clients at risk.
193. A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the
client states, "I’m feeling sad. I don’t want to talk now." Which of the following responses
should the nurse make?
A. "It will help you feel better if you talk about it."
B. "I’ll come back when you feel like talking."
C. "I’ll stay with you a few minutes."
D. "Coming with me to the day room will take your mind off your troubles."
Answer: C. "I’ll stay with you a few minutes."
Rationale:
A. Providing false reassurance minimizes the client’s concerns and might stop the client from
sharing feelings with the nurse.
B. Leaving the client does not address her immediate needs and might make her feel more
isolated.
C. Offering of self is a therapeutic communication technique that promotes the nurse-client
relationship.
D. Offering advice makes the client dependent on the nurse and prevents individual problem
solving.
194. A nurse is admitting a client to an alcohol abuse program. The client states, "I’m here
because of my boss. It was part of my job to go to parties and drink with clients." The client’s
statement is an example of which of the following defense mechanisms?
A. Reaction-formation
B. Compensation

C. Rationalization
D. Suppression
Answer: C. Rationalization
Rationale:
A. Reaction-formation occurs when the client behaves in an opposite manner from his actual
feelings.
B. Compensation occurs when a person overcomes a weakness by focusing on a more desirable
behavior or trait.
C. The client is demonstrating rationalization by trying to justify his alcohol use by blaming his
boss.
D. Suppression occurs when a person consciously denies a feeling that is disturbing to him.
195. A nurse in an acute mental health facility is caring for a client who jumps out of her chair
and begins to shout angrily at the clients around her. Which of the following actions should the
nurse take first?
A. Call for assistance to place the client in restraints.
B. Escort the client to an unlocked seclusion room.
C. Offer the client a PRN antianxiety medication.
D. Speak to the client calmly, giving simple directions.
Answer: D. Speak to the client calmly, giving simple directions.
Rationale:
A. The nurse might need to call for assistance to place the client in restraints, but another action
is the priority.
B. The nurse might need to escort the client to either an unlocked or a locked seclusion room, but
another action is the priority.
C. The nurse should offer the client a PRN antianxiety medication, but another action is the
priority.
D. When providing care for an angry client, the nurse should first use the least restrictive
intervention. Therefore, the nurse should speak to the client calmly and give her simple
directions. This action might help prevent escalation of the client’s angry behavior.

196. A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of
the following actions is the highest priority?
A. Protecting the client from injury
B. Determining the cause of the client's anxiety
C. Ensuring that the client feels safe
D. Identifying the client's coping skills
Answer: A. Protecting the client from injury
Rationale:
A. The greatest risk to this client is harm to himself through suicide or other injury when not in
control of his actions, or to others while experiencing panic-level anxiety. Therefore, the priority
is to protect the client from injury. The presence of panic-level anxiety is a risk factor for suicide.
B. Determining the cause of the client's anxiety is an important part of crisis intervention.
However, another action is the priority.
C. Promoting feelings of safety and security is an important part of crisis intervention. However,
another action is the priority.
D. Identifying the client's coping skills is an important part of crisis intervention. However,
another action is the priority.
197. A home-health nurse is assessing a client who has obsessive–compulsive disorder (OCD)
and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this
behavior is an attempt to accomplish which of the following?
A. Decrease anxiety.
B. Prevent aggressive and impulsive behaviors.
C. Manipulate others.
D. Decrease the time available for interaction with people.
Answer: A. Decrease anxiety.
Rationale:
A. Repetitive, ritualistic behavior is an attempt by a client who has OCD to decrease anxiety.
B. Aggressive and impulsive behaviors are common in certain types of mental illness, such as
antisocial personality disorder. However, the client who has OCD does not perform compulsions
in order to prevent aggressive and impulsive behaviors.

C. Manipulation is a component of certain mental health disorders, such as antisocial personality
disorder. However, it is not a component of OCD and it is not the purpose of the behavior.
D. Constant repetitive behavior may take time away from the client for socialization. However,
this is not the purpose of the behavior.
198. A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a
sexual assault. Which of the following is an expected finding?
A. Sleeping 12 hr or more each day.
B. Increasing sense of attachment to others.
C. Constant need to talk about the event.
D. Increasing feelings of anger.
Answer: D. Increasing feelings of anger.
Rationale:
A. Insomnia is a finding associated with PTSD.
B. Detachment and avoidance of relationships are findings associated with PTSD
C. Avoidance of discussing the event is a finding associated with PTSD.
D. Increasing anger and irritability are findings associated with PTSD.
199. A nurse is assessing a client who has a diagnosis of conversion disorder. Which of the
following is an expected finding?
A. Frequent manic episodes.
B. Refusal of medication due to paranoia.
C. Preoccupation with manifestations of various illnesses.
D. Involuntary loss of a sensory function.
Answer: D. Involuntary loss of a sensory function.
Rationale:
A. Severe depression, rather than mania, is a finding associated with conversion disorder.
B. Medication seeking behavior and dependence are findings associated with conversion
disorder.
C. Preoccupation with manifestations of various illnesses is associated with illness anxiety
disorder.

D. The involuntary loss of a sensory function such as hearing or vision is a finding associated
with conversion disorder.
200. A nurse is assessing a client who has illness anxiety disorder. Which of the following
findings should the nurse expect?
A. Prior physical health followed by the need for two surgeries within the last three months.
B. Obsession over a fictitious defect in physical appearance.
C. Sudden unexplained loss of peripheral sensation.
D. Constant worry about the undiagnosed presence of an illness.
Answer: D. Constant worry about the undiagnosed presence of an illness.
Rationale:
A. Prior health followed by the need for two surgeries in the last three months suggests a
physical illness rather than illness anxiety disorder. Findings of illness anxiety disorder must be
present for at least six months for a diagnosis to be determined.
B. Obsession over a fictitious defect in physical appearance is associated with body dysmorphic
disorder.
C. Sudden sensory losses, without a medical explanation, are associated with conversion
disorder.
D. Clients who have illness anxiety disorder constantly worry about the presence of a serious
illness even though medical tests do not support this concern.
201. A nurse is planning care for a client who demonstrates manipulative behavior. Which of the
following interventions should be included in the plan of care?
A. Allow manipulation so as to not raise the client's anxiety.
B. Avoid discussing past behaviors with the client.
C. Institute consequences for manipulative behavior.
D. Bargain with the client to discourage manipulative behavior.
Answer: C. Institute consequences for manipulative behavior.
Rationale:
A. The nurse should not allow manipulation to occur and should prepare to intervene to
discourage client attempts.

B. The nurse should discuss both past and present behaviors with the client to assist the client in
gaining insight about behaviors that are unacceptable to others.
C. The nurse should work with the client to develop a behavior plan that includes specific
consequences for manipulative behavior.
D. The nurse should not bargain with the client as this promotes continued manipulative
behavior.
202. A nurse in a mental health facility is caring for a client in the busy facility dining room
during lunchtime when suddenly the client becomes angry and throws a chair. Which of the
following interventions should the nurse perform first?
A. Restrain the client to prevent injury to himself or others.
B. Place the client in a monitored seclusion room until he is calm.
C. Administer a PRN antianxiety medication.
D. Attempt to talk the client down.
Answer: D. Attempt to talk the client down.
Rationale:
A. Restraint might be necessary to prevent injury for the client whose behavior is escalating, but
another action is the priority.
B. Placing the client in a monitored seclusion room might be necessary for a client whose
behavior is escalating, but another action is the priority.
C. The nurse might need to administer an antianxiety medication to calm the client whose
behavior is escalating, but another action is the priority.
D. The first action the nurse should take using the safety/risk reduction priority-setting
framework is to attempt to de-escalate the client’s anger and aggression by talking the client
down in a calm, nonthreatening manner.
203. A nurse is planning care for a client who has dependent personality disorder. Which of the
following actions should the nurse plan to take?
A. Monitor the client closely to prevent self-mutilation.
B. Set limits to prevent exploitation of other clients.
C. Discourage flamboyant or seductive behaviors.

D. Give positive feedback when client is assertive with staff or clients.
Answer: D. Give positive feedback when client is assertive with staff or clients.
Rationale:
A. Self-mutilation is common in clients who have borderline personality disorder but not
dependent personality disorder.
B. Exploitation of others is common in clients who have antisocial personality disorder but not
dependent personality disorder.
C. Flamboyant or seductive behavior is commonly seen in clients who have histrionic personality
disorder but not dependent personality disorder.
The client who has dependent personality disorder has great difficulty demonstrating assertive
behavior and commonly relies on others to make decisions. The nurse should encourage the
client to be more assertive and independent.
204. A nurse is providing teaching for a client who has a recent diagnosis of depression. Which
of the following should the nurse identify as a primary risk factor for this disorder?
A. Recent history of stressful, positive life events.
B. Past history of childhood trauma.
C. Being an only child.
D. Having elevated levels of serotonin.
Answer: B. Past history of childhood trauma.
Rationale:
A. A recent history of negative stressful events is a primary risk factor for depression.
B. A history of trauma in childhood is a primary risk factor for depression.
C. Birth order, such as being an only child, is not a risk factor for depression.
D. A decreased level of serotonin is associated with depression.
205. A nurse in an acute mental health facility is caring for a client who has major depressive
disorder. Since her admission 3 days ago, she has not put on clean clothes, washed her hair, or
participated in any of the unit activities. On this day, the nurse observes that she is wearing clean
clothes and has combed her hair. Which of the following responses should the nurse make?
A. "Oh, I'm so pleased that you finally put on clean clothes."

B. "Why did your wear clean clothes and comb your hair today?"
C. "Your mood must be lifting because you have on clean clothes and have combed your hair."
D. "I see that you have on clean clothes and have combed your hair."
Answer: D. "I see that you have on clean clothes and have combed your hair."
Rationale:
A. This comment implies that the client should value the nurse's approval, which is a
nontherapeutic communication technique.
B. Asking a "why" question might make the client feel defensive and is nontherapeutic.
C. The nurse is attempting to interpret the client's feelings, which is not a therapeutic technique.
The client should be encouraged to tell about her feelings.
D. This comment provides recognition of the client's behavior and efforts at self-care without
making a value judgment or offering approval. This is a therapeutic communication technique.
206. A nurse is caring for a client who has depression. The client refuses to get out of bed, go to
activities, or participate in any of the unit's programs. Which of the following responses should
the nurse make?
A. "You really need to follow the rules of the unit and get out of bed."
B. "If you do not get out of bed you will not receive your meal."
C. "I will help you get ready and then you can rest after activities."
D. "You should rest until you feel able to join the group."
Answer: C. "I will help you get ready and then you can rest after activities."
Rationale:
A. This statement is demonstrates disapproval, which is a nontherapeutic communication
technique.
B. This statement is threatens the client with punishment. The threat to withhold a meal as a
consequence is unethical.
C. This statement shows caring by the nurse and provides for a balance between activity and rest
which is an appropriate intervention for the client who has depression.
D. This statement provides approval of the client's refusal to get out of bed, which is
nontherapeutic and does not meet the needs of the client.

207. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The
client is doing calisthenics in the client dining room during lunchtime instead of eating. Which of
the following statements should the nurse make?
A. "You are already too thin and exercise is not good for you. Go sit down somewhere and eat
something."
B. "Come with me. Here is a milkshake to drink."
C. "We need you to decide what activities you will do today."
D. "You will need to leave the dining room right now and go somewhere else to exercise."
Answer: B. "Come with me. Here is a milkshake to drink."
Rationale:
A. Telling the client he is too thin and that exercise is not good for him is likely to precipitate an
argument. The nurse should avoid value judgments and unwanted advice. Telling the client to sit
down and eat something is vague and the client is unlikely to be able to comply, since focusing
on any activity is difficult during mania.
B. When working with a client who is experiencing mania, the nurse should provide short, firm,
and concise directions, which can provide a feeling of safety for the client and can distract the
client from inappropriate activities, such as vigorous exercise. An appropriate activity for the
client is to accompany the nurse to a quiet place away from the clients who are trying to eat.
Client nutrition is important, but the client often needs foods that can be held in the hand and
eaten easily while walking. The client is unlikely to be able to sit in one place for long enough to
complete a meal when experiencing mania.
C. The client experiencing mania is unable to focus and to use judgment to make appropriate
decisions. The nurse must redirect the client to more appropriate behaviors by being consistent
and enforcing client expectations.
D. The nurse should avoid statements that can precipitate an argument with the client. This
statement demonstrates disapproval, which can precipitate a power struggle with the client. The
nurse should remain neutral rather than giving advice.
208. A nurse is planning care for a client who has depression. The nurse notes that the client has
weight loss, an inability to concentrate, an inability to complete everyday tasks, and a preference
to sleep all day. Which of the following interventions should be included in the plan of care?

A. Discourage rest periods during the daytime.
B. Instruct family to avoid visiting during mealtimes.
C. Offer three or four large meals daily.
D. Give the client extra time to communicate needs.
Answer: D. Give the client extra time to communicate needs.
Rationale:
A. Clients who have vegetative signs of depression need to balance rest and activity because
fatigue can increase depression. The client should be allowed to rest after activities, although
times of actual sleep should be minimized during the daytime.
B. The nurse should encourage family to be present during mealtimes to reinforce caring and
self-esteem.
C. Clients who have vegetative signs of depression are at risk for inadequate intake. Therefore,
the nurse should offer frequent high-calorie snacks and fluids. Large meals are often poorly
tolerated by the client who has anorexia and for whom concentrating on a large meal is difficult.
D. Clients who have vegetative signs of depression have slowed thought processes and might
take extra time to reply to questions or to verbalize thoughts. The nurse should display patience
and give the client extra time to communicate.
209. A nurse is caring for a client 3 days after admission for treatment of depression. The client
leaves her current activity, approaches the nurse and states, "There's no reason to go on living. I
just want to end it all." Which of the following actions should the nurse take?
A. Ask the client if she has a plan to commit suicide.
B. Recognize the attempt at manipulation and escort the client back to her activity.
C. Assist the client to her room and allow her to rest before resuming activity.
D. Notify the client's family and request a visitor to stay with the client until thoughts of suicide
are gone.
Answer: A. Ask the client if she has a plan to commit suicide.
Rationale:
A. The nurse should take seriously all statements regarding suicide. Asking the client if she has a
suicide plan is a specific question that the nurse should include when assessing a client who has
possible suicidal ideation.

B. Taking the client back to the activity does not take seriously the statement regarding thoughts
of suicide. There is no reason to consider the client's statement as an attempt at manipulation.
C. The nurse should take seriously all statements regarding suicide. Clients who have thoughts of
suicide should not be left unattended. Clients in acute care facilities who are considering suicide
are placed on suicide precautions and are monitored constantly so that they can be kept safe.
D. The nurse should take seriously all statements regarding suicide. Suicide precautions include
constant observation by a staff member.
210. A nurse in an acute care mental health facility is caring for a client who has depression.
After 3 days of treatment, the nurse notices that the client suddenly seems cheerful and relaxed
and there are no longer signs of a depressive state. Which of the following interventions is
appropriate to include in the plan of care?
A. Encourage family to take the client out of the facility for short periods of time.
B. Reward the client for her change in behavior.
C. Monitor the client's whereabouts at all times.
D. Ask the client why her behavior has changed.
Answer: C. Monitor the client's whereabouts at all times.
Rationale:
A. This intervention does not recognize the risk associated with this sudden change in behavior.
B. Rewarding the client implies approval of the behavior which is nontherapeutic. This
intervention does not recognize that treatment for depression with medication generally takes 1
to 3 weeks before improvement is seen.
C. Clients who have depression and exhibit a sudden change in behavior are at risk for suicide
and suicide precautions should be included in the plan of care. Antidepressant medications
generally take 1 to 3 weeks before improvement is seen. A cheerful mood with no signs of a
depressive state 3 days after treatment begins might indicate that the client has made a decision
to commit suicide.
D. Asking the client a "why" question is nontherapeutic and fosters a defensive reaction from the
client.

211. A nurse working in suicide prevention is discussing suicide interventions with a newly hired
nurse. Which of the following statements indicates that the newly hired nurse understands when
a tertiary intervention is needed?
A. "I should perform screenings to identify clients at risk for suicide."
B. "I should recognize the lethality of the suicide plan."
C. "I should provide counseling for the family following the suicide of a client."
D. "I should provide a safe environment to prevent the client from committing suicide."
Answer: C. "I should provide counseling for the family following the suicide of a client."
Rationale:
A. Identifying clients at risk for suicide is an example of primary intervention.
B. Recognizing the lethality of the suicide plan is an example of secondary intervention.
C. Providing counseling for the family following the suicide of a client is an example of tertiary
intervention. Following the suicide of a client, family and friends are, themselves, at risk for
suicide, and can be helped by therapeutic communication. They may require referral for grief
counseling or other supportive measures.
D. Providing a safe environment to prevent the client from committing suicide is an example of
secondary intervention.
212. A nurse in an acute care mental health facility is assessing a client who has bipolar disorder.
Which of the following findings indicates the client is at risk for suicide?
A. The client has begun playing basketball with several other clients during the past month.
B. The client identifies with problems expressed by other clients.
C. he client's behavior has become impulsive in the past few weeks.
D. The client states she wants to go home to be with her children and partner.
Answer: C. he client's behavior has become impulsive in the past few weeks.
Rationale:
A. The presence of social supports among other clients can be a protective factor against suicide.
B. Identification with problems expressed by other clients is a defense mechanism that can be
used consciously or unconsciously by a person. However, it is not an indicator for suicide risk.
C. The presence of impulsive behavior is a primary risk factor for suicide and clients who have
mania can act in a manner which is hostile, aggressive, and impulsive.

D. The presence of social support and a sense of responsibility toward family is a protective
factor for suicide.
213. A nurse is caring for a client who is experiencing a manic episode. Other clients begin to
complain about her disruptive behavior on the unit. Which of the following actions should the
nurse take?
A. Warn the client that further disruptions will result in seclusion.
B. Ignore the client's behavior, realizing it is consistent with her illness.
C. Set limits on the client's behavior and be consistent in approach.
D. Ask the client to recommend consequences for her disruptive behavior.
Answer: C. Set limits on the client's behavior and be consistent in approach.
Rationale:
A. Providing a warning does not resolve the current behavior and encourages manipulation.
B. Ignoring the client's behavior does not address the needs of the client and other clients on the
unit.
C. When caring for a client who is experiencing a manic episode, the nurse should communicate
acceptable behavior to the client and should be consistent with consequences when the behavior
plan is not followed.
D. Asking the client to recommend consequences encourages manipulation and also would be
very difficult for the client who has mania and is unable to focus and use good judgment.
214. A nurse is interviewing a client during admission to an alcohol treatment center. Which of
the following approaches should the nurse take?
A. Maintain a nonjudgmental attitude.
B. Avoid displaying an emotional response.
C. Offer sympathetic support.
D. Verbalize disapproval of the client's substance abuse.
Answer: A. Maintain a nonjudgmental attitude.
Rationale:

A. When developing a therapeutic relationship with any client, including a client who has an
addictive disorder, it is important that the nurse remain nonjudgmental, showing positive regard
for the client as a person.
B. A lack of any emotional response can be interpreted as a lack of caring for the client and is
nontherapeutic. The nurse should maintain genuineness when caring for clients.
Genuineness includes being aware of one's feelings and communicating with the client in a
professional but spontaneous manner.
C. Offering sympathy is nontherapeutic. The nurse should instead show empathy and
demonstrate that she objectively understands the client's feelings, but does not feel sympathy for
the client.
D. Verbalizing disapproval is nontherapeutic and can make the client feel defensive. Therefore,
verbalizations of disapproval can interfere with the development of a therapeutic nurse-client
relationship.
215. A nurse in an acute care facility is assessing a client who had hip surgery and has
Alzheimer's disease. The nurse asks the client how therapy went that morning. Which of the
following statements by the client should the nurse document as confabulation?
A. "This morning, this morning, this morning…"
B. "It was good. The Queen of England visited me there."
C. "I just don't remember what I did this morning."
D. "Snip, snap. Take a nap."
Answer: B. "It was good. The Queen of England visited me there."
Rationale:
A. Perseveration is the repeating of words or behaviors by a client who has brain damage, such
as Alzheimer's disease. Perseveration can worsen when the client is under increased stress.
B. Confabulation occurs when a client who has dementia unconsciously makes up or fills in
made-up information when she has memory loss. Confabulation is sometimes mistaken for lying.
However, lying is done consciously and confabulation is done unconsciously to maintain selfesteem.
C. Memory loss occurs in Alzheimer's disease. The client saying that she does not remember
what happened is not an example of confabulation.

D. This statement is an example of clang association, which is sometimes seen in clients who
have schizophrenia. It is not an example of confabulation.
216. A nurse is planning care for a client who has dementia. Which of the following interventions
should the nurse include in the plan of care?
A. Provide a cognitively stimulating environment.
B. Rotate staff to prevent caregiver role strain.
C. Limit the client's choices for daily activities.
D. Use confrontation to manage negative behavior.
Answer: C. Limit the client's choices for daily activities.
Rationale:
A. Clients who have dementia should have a low-stimulation environment to decrease client
anxiety.
B. Clients who have dementia should have consistent staffing assignments to minimize stress and
confusion. Caregiver role strain might occur if a client is cared for a home and the family has
difficulty coping with constant stressors.
C. Limiting the client's choices is appropriate for a client who has dementia as this intervention
decreases the client's level of anxiety.
D. The nurse should use distraction to manage negative behavior and should avoid the use of
confrontation which may cause escalation of aggressive behaviors.
217. A nurse is teaching the family of an older adult client who has a new diagnosis of dementia.
Which of the following statements should the nurse include include in the teaching?
A. "Dementia is characterized by a sudden onset of confusion."
B. "An altered level of consciousness is associated with dementia."
C. "The signs of dementia are progressive and irreversible."
D. "Dementia can be triggered by a high fever or dehydration."
Answer: C. "The signs of dementia are progressive and irreversible."
Rationale:

A. Delirium, rather than dementia, is characterized by a sudden onset. The client who has
delirium might experience confusion, decreased ability to focus, and disorganized thinking.
Dementia has an onset which occurs slowly over months or years.
B. Delirium, rather than dementia, results in an altered level of consciousness.
C. Dementia is a progressive disorder that is irreversible.
D. The presence of a medical condition, such as infection or dehydration might cause the onset
of delirium, but not of dementia. Dementia can be caused by such disorders as Alzheimer's
disease, long-term alcohol use disorder, and Parkinson's disease.
218. A nurse is collecting a health history on a client who has a diagnosis of Wernicke-Korsakoff
syndrome. Which of the following is an expected finding?
A. Family history of Alzheimer’s disease.
B. Personal history of alcohol use disorder.
C. Undergoing current treatment for HIV.
D. Current rehabilitation for opiate addiction.
Answer: B. Personal history of alcohol use disorder.
Rationale:
A. Alzheimer's disease is a type of primary dementia and is not a risk factor for WernickeKorsakoff syndrome.
B. Wernicke-Korsakoff syndrome is a type of secondary dementia as a result of thiamine
deficiency that is commonly associated with alcohol use disorder. The syndrome results in
confusion and memory loss and is treated with thiamine replacement therapy.
C. HIV can result in a cognitive disorder called HIV-1-associated cognitive/motor complex, but
this is not related to Wernicke-Korsakoff syndrome.
D. Although use of some substances, such as inhalants, can cause a neurocognitive disorder,
opiate addiction is not associated with Wernicke-Korsakoff syndrome or with neurocognitive
disorders.
219. A nurse is developing a plan of care for a newly admitted client who has schizophrenia and
experiences frequent hallucinations and paranoid delusions. Which of the following actions
should the nurse plan to take?

A. Place the client in seclusion if visual hallucinations are present.
B. Limit the number of questions asked during assessments
C. Use frequent touch to provide client support.
D. Directly tell the client that delusions are not real.
Answer: B. Limit the number of questions asked during assessments
Rationale:
A. Placing the client in seclusion would increase the severity of the hallucinations. Seclusion
should be an intervention of last resort for client safety after considering other actions.
B. Minimizing the number of questions is appropriate since a client who has acute schizophrenia
has difficulty concentrating on information and answering assessment questions. The nurse
should plan to use other sources of client information, such as medical records, family members,
or reports from other interprofessional sources.
C. Touch can be perceived by the client as threatening and should be avoided. If touch is
necessary, such as when taking the client's pulse, the nurse should ask the client before touching.
D. Negating the client's perception of a delusion will increase anxiety and agitation and is
nontherapeutic. The nature of delusions is such that the client does not accept proof that
delusional beliefs are not real.
220. A nurse is talking with a client who has schizophrenia. Suddenly the client states, "I'm
frightened. Do you hear that? The voices are telling me to do terrible things." Which of the
following responses by the nurse is appropriate?
A. "You need to tell the voices to leave you alone."
B. "You need to understand that there are no voices."
C. "What are the voices telling you to do?"
D. "Why do you think you are hearing the voices?"
Answer: C. "What are the voices telling you to do?"
Rationale:
A. This statement acknowledges the reality of the voices and encourages the client to argue with
the voices, both of which are nontherapeutic approaches for communication with a client who is
experiencing a hallucination.

B. Negating the client's perception of the hallucination is a nontherapeutic approach for
communication with a client who is experiencing a hallucination.
C. This statement recognizes the risk involved with a command hallucination and asks the client
directly about the hallucination. This is a therapeutic approach to communicating with a client
who is experiencing a hallucination.
D. Asking a "why" question is nontherapeutic and increases the defensiveness of a client
experiencing a hallucination.
221. A nurse overhears a client who has schizophrenia talking to herself. The client keeps stating,
"The flak alas are here. The flak alas are here." The nurse correctly recognizes the client's use of
the word falbala as an example of which of the following alterations in speech?
A. Echolalia
B. Clang association
C. Neologism
D. Word salad
Answer: C. Neologism
Rationale:
A. Echolalia is the constant repeating of what another person is saying.
B. Clang association is the use of words that rhyme.
C. The nurse correctly identifies this alteration in speech as a neologism which is the use of a
fictitious word that has meaning only to the client.
D. Word salad is the use of real words spoken in a sequence so that the words have no logical
meaning with one another.
222. A charge nurse overhears another nurse talking with a client who has schizophrenia.
Suddenly the client yells, "I am the devil! I am God! Open the gate for me!" Which of the
following replies by the nurse requires intervention?
A. "It sounds frightening to feel like both God and the devil at the same time."
B. "I don't understand. Can you tell me what that means?"
C. "Are you saying that you are both good and bad?"
D. "There is no gate for me to open."

Answer: D. "There is no gate for me to open."
Rationale:
A. This reply explores possible feelings behind the client's delusion. This minimizes the focus on
the delusion and places the focus on the client's feelings.
B. This reply asks the client directly about the delusion which is appropriate for communicating
with a client who is experiencing a delusion. Although the nurse should not place extended focus
on the delusion it is appropriate to briefly assess the meaning of the delusion.
C. This reply explores the feelings behind the client's delusion which is appropriate for
communicating with a client who is experiencing a delusion. Although the nurse should not place
extended focus on the delusion, it is appropriate to briefly assess the meaning of the delusion and
the client's feelings.
D. This reply can be viewed as argumentative by the client and is nontherapeutic for
communicating with a client who is experiencing a delusion.
223. A nurse is reading the medical record for a client who has schizophrenia which indicates
that the client exhibits depersonalization. Which of the following statements by the client
confirms that she is experiencing depersonalization?
A. "I have broken off all my past relationships because my friends and family are trying to kill
me."
B. "I hear voices telling me that I have been bad."
C. "My hands and feet are much smaller than they used to be."
D. "Everything in this room has changed and I don't recognize it anymore."
Answer: C. "My hands and feet are much smaller than they used to be."
Rationale:
A. The client who has schizophrenia might experience paranoia and have the delusion that others
are trying to harm her. However, this is not an example of depersonalization.
B. A client who has schizophrenia might experience auditory hallucinations, which often include
"voices" talking to the client. However, this is not an example of depersonalization.
C. The client who experiences depersonalization might feel that parts of her body belong to
someone else or are different in some way. Depersonalization is experienced as a loss of personal
identity.

D. Feeling that the client's environment has changed in some way is an example of derealization,
rather than depersonalization.
224. A nurse is conducting a group therapy meeting and is sharing a humorous story. When the
group laughs at the story, a client who has schizophrenia jumps up and runs out while yelling,
"You are all making fun of me." Which of the following behaviors is this client displaying?
A. Grandeur
B. Flight of ideas
C. Erotomania
D. Ideas of reference
Answer: D. Ideas of reference
Rationale:
A. Grandeur describes behavior in which the client believes he is extremely important or
powerful.
B. Flight of ideas is an alteration in speech in which a client's speech moves rapidly from one
thought to the next and the client verbalizes one unrelated idea after another.
C. Erotomania describes behavior in which the client believes another individual desires him
romantically.
D. Ideas of reference occur when a client believes that conversations of others always concern
him and that others are ridiculing him.
225. A nurse is caring for a client who has schizophrenia. The client states that he hears voices
telling him to do "bad things." The nurse correctly identifies this finding as which of the
following?
A. Command hallucination
B. Gustatory hallucination
C. Cognitive distortion
D. Somatic delusion
Answer: A. Command hallucination
Rationale:
A. This finding is correctly identified as a command hallucination.

B. A gustatory hallucination is when a client experiences a taste that is not actually present.
C. A cognitive distortion, or automatic thoughts, refers to negative thoughts that occur without
thinking in some clients. An example would be a client who, when asked to perform a task
always says, "I am not able to do that." Cognitive therapy can assist the client in changing
cognitive distortions to positive statements.
D. A somatic delusion when a client believes his body is changing in some way, such as the
belief that internal organs are rotting.
226. A nurse is planning care for a client who has paranoid schizophrenia. Which of the
following interventions should be included in the plan of care?
A. Rotate staff assignments for this client.
B. Use touch to calm the client during periods of anxiety.
C. Check the client's mouth after the client takes medication.
D. Assign an assistive personnel to feed the client at mealtimes.
Answer: C. Check the client's mouth after the client takes medication.
Rationale:
A. Clients who have paranoid schizophrenia benefit from consistent staffing assignments which
promote trust.
B. Clients who have paranoid schizophrenia often misinterpret actions as sexual advances and
therefore touch can increase paranoia and aggression.
C. This action is appropriate for clients who have paranoid schizophrenia as it helps assure that
the client is swallowing medication.
D. Clients who have paranoid schizophrenia are often fearful that others are trying to poison
them. Assigning an assistive personnel to feed the client can take away the client's sense of
control and can increase feelings of paranoia.
227. A nurse is reviewing the history and physicality of an adolescent client who has conduct
disorder. Which of the following is an expected finding?
A. Death of client's father two months ago
B. Experiences frequent facial tics
C. Suspended from school several times in the past year

D. Adheres strictly to routines
Answer: C. Suspended from school several times in the past year
Rationale:
A. Risk factors for conduct disorder include harsh discipline with inconsistent parenting or
growing up in an institutional environment. Death of the client's father two months ago could
trigger a stress/trauma disorder, such as acute stress disorder, but does not put the client at risk
for conduct disorder.
B. A client who has Tourette's disorder often experiences facial and verbal tics and other motor
difficulties.
C. Conduct disorder is an impulse-control disorder which includes a long-term pattern of
violating the rights of others and performing violent or hostile acts.
D. A client who has autism spectrum disorder experiences difficulty with communication and
interaction with others, might also become fixated with certain objects, and adheres strictly to
routines.
228. A nurse is reviewing abnormal laboratory values for four clients who have schizophrenia
and take clozapine. For which of the following clients should the nurse withhold the medication
and notify the provider immediately to have clozapine therapy discontinued?
A. A client who has a WBC of 2,900 cells/mm3
B. A client who has a hematocrit of 55%
C. A client who has a serum potassium of 3.3 mEq/L
D. A client who has a BUN of 22 mg/dL
Answer: A. A client who has a WBC of 2,900 cells/mm3
Rationale:
A. A white blood cell count of 2,900 cells/mm3 is below the normal reference range of 5000 to
10000 cells/mm3 . The client who takes clozapine is at risk for agranulocytosis; therefore, a
client who has a WBC of less than 3000 mm3 should have clozapine withheld and treatment
stopped until the WBC returns to normal. Clozapine should be permanently stopped if a client’s
WBC falls below 2000 mm3.
B. A hematocrit of 55% is above the recommended reference range of 37% to 47% for females
and 42% to 52% for males, but is not a contraindication for clozapine therapy.

C. A serum potassium of 3.3 mEq/L is below the recommended reference range of 3.5 to 5.0
mEq/L . A low or high potassium level should be reported, but is not a contraindication for
clozapine therapy.
D. A BUN of 22 mg/dL is above the recommended reference range to 10 to 20 mg/dL and should
be reported, but is not a contraindication for clozapine therapy.
229. A nurse is assessing a client who is receiving treatment with multiple antipsychotic
medications and who suddenly became ill. Findings include blood pressure changes,
hyperpyrexia, and diaphoresis. The nurse should recognize that which of the following adverse
effects may be occurring?
A. Tardive dyskinesia
B. Neuroleptic malignant syndrome
C. Acute dystonia
D. Pseudo parkinsonism
Answer: B. Neuroleptic malignant syndrome
Rationale:
A. Tardive dyskinesia is characterized by chronic involuntary movements of the face, trunk,
and/or extremities. It does not include blood pressure changes, hyperpyrexia, or diaphoresis.
B. The client's findings indicate possible neuroleptic malignant syndrome which is a potentially
life-threatening adverse effect of antipsychotic medications. The nurse should promptly
recognize and report findings of neuroleptic malignant syndrome since prompt treatment is
necessary.
C. Acute dystonia is characterized by acute muscle spasms of the head and neck. It occurs during
the first few days of antipsychotic medication administration and does not include blood pressure
changes, hyperpyrexia, or diaphoresis.
D. Pseudo parkinsonism is characterized by the temporary presence of findings associated with
Parkinson's disease such as tremors and impaired gait. It does not include blood pressure
changes, hyperpyrexia, or diaphoresis.
230. A nurse is providing teaching for a client who has schizophrenia and a new prescription for
risperidone. Which of the following statements should the nurse include in the teaching?

A. Increase your fluid and fiber intake to prevent constipation.
B. Have your blood pressure checked frequently for hypertension.
C. Expect to have your blood checked weekly for serum electrolyte imbalances.
D. Increase caloric intake to prevent weight loss.
Answer: D. Increase caloric intake to prevent weight loss.
Rationale:
A. Constipation is a common adverse effect of risperidone and the client should be taught
strategies to prevent constipation, such as increasing the amount of fiber in the diet.
B. Orthostatic hypotension is a common adverse effect of risperidone and the client should be
monitored for tachycardia and decreases in blood pressure when arising from a sitting or lying
position.
C. Changes in serum electrolytes are not expected while taking risperidone. The client should be
taught that CBC and liver function will be checked monthly while taking risperidone since
neutropenia and jaundice are possible adverse effects.
D. Weight gain, dyslipidemia, and increases in blood glucose are common adverse effects of
risperidone.
231. A nurse is providing teaching for a client who has a new prescription for clozapine. Which
of the following statements indicates the client understands the teaching?
A. "This medication will help prevent seizures."
B. "This medication will be administered by intramuscular injection every 2 weeks."
C. "I should expect to develop ringing in my ears while taking this medication."
D. "I will rise slowly from a lying position to prevent fainting while taking this medication."
Answer: D. "I will rise slowly from a lying position to prevent fainting while taking this
medication."
Rationale:
A. Clozapine is prescribed for the treatment of psychotic symptoms and has a potential adverse
effect of seizure activity.
B. Clozapine, a second generation antipsychotic medication, is available orally and is not
administered by IM injection.
C. Clozapine can cause blurred vision, but does not affect hearing or cause ringing in the ears.

D. Clozapine can cause orthostatic hypotension, especially during the first few weeks of therapy.
The client should be taught to rise slowly from a lying or sitting position.
232. A nurse is evaluating teaching for a client who has newly diagnosed depression and a new
prescription for bupropion. Which of the following statements by the client indicates
understanding of the teaching?
A. "I may develop a slow heartbeat while taking bupropion."
B. "I can drink one glass of wine with dinner each day while taking bupropion."
C. "I may not notice a lifting of my mood for at least 2 weeks."
D. "I should watch for increased salivation and drooling while taking bupropion."
Answer: C. "I may not notice a lifting of my mood for at least 2 weeks."
Rationale:
A. Bupropion can cause tachycardia but not bradycardia.
B. The client should be taught to avoid alcohol. Central nervous system depressants, including
alcohol, increase the risk for seizures while taking bupropion.
C. Bupropion is a norepinephrine-dopamine reuptake inhibitor (NDRI). As with other
antidepressants, it can take 2 to 4 weeks for therapeutic effects to occur when taking bupropion.
D. Bupropion commonly causes dry mouth rather than increased salivation. The nurse should
instruct the client to sip water or use other strategies to prevent the discomfort from dry mouth.
233. A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome.
Which of the following is the priority nursing intervention?
A. Administering an anticonvulsant.
B. Padding side rails to prevent injury.
C. Preparing for artificial ventilation.
D. Applying a cooling blanket.
Answer: C. Preparing for artificial ventilation.
Rationale:
A. Administering an anticonvulsant is an appropriate intervention for serotonin syndrome;
however another intervention is the priority.

B. The nurse should pad side rails to prevent injury from delirium or seizure activity; however,
another intervention is the priority.
C. Delirium, severe vital sign changes, and apnea may be present in the client who has serotonin
syndrome. Preparing for artificial ventilation is the priority intervention when taking the airway,
breathing, circulation approach to client care.
D. Applying a cooling blanket is an appropriate intervention for serotonin syndrome; however
another intervention is the priority.
234. A nurse is preparing to administer selegiline for a client who is admitted with major
depression. Which of the following actions should the nurse take?
A. Apply to dry skin on the client’s upper thigh.
B. Administer subcutaneously in the client’s abdomen using a 27 gauge needle.
C. Give the medication orally at bedtime to promote sleep.
D. Inject the medication intramuscularly in a large muscle.
Answer: A. Apply to dry skin on the client’s upper thigh.
Rationale:
A. Selegiline, a monoamine oxidase inhibitor (MAOI) is administered only by the transdermal
route to treat depression. It can be administered orally to treat Parkinson’s disease and other
disorders.
B. Selegiline is not administered subcutaneously. It is administered only by the transdermal route
to treat depression.
C. Selegiline is administered orally to treat Parkinson’s disease as an adjunct to
levodopa/carbidopa therapy. Selegiline is administered is administered only by the transdermal
route to treat depression.
D. Selegiline is not administered intramuscularly. It is administered only by the transdermal
route to treat depression.
235. A nurse is reviewing medications for a newly admitted client who has bipolar disorder and
is experiencing mania. Which of the following client prescriptions should the nurse realize is
expected to reduce the client’s mania?
A. Fluvastatin

B. Carbamazepine
C. Lorazepam
D. Propranolol
Answer: B. Carbamazepine
Rationale:
A. Fluvastatin, an antilipemic medication, is not used to treat bipolar disorder, but is used to
reduce cholesterol levels.
B. Carbamazepine, an antiseizure medication and a mood stabilizer, is prescribed to treat and
prevent mania in clients who have bipolar disorder.
C. Lorazepam, a sedative, hypnotic medication is used to treat anxiety and is not indicated to
reduce mania or hypomania.
D. Propranolol, a beta-blocker, is used to treat hypertension and other heart conditions, as well as
certain anxiety disorders. It is not indicated to reduce mania or hypomania.
236. A nurse is assessing a client who has schizophrenia which has been treated with
fluphenazine for several years. Which of the following findings should the nurse document as
manifestations of tardive dyskinesia (TD)?
A. Shuffling gait
B. Constant tapping of feet when sitting
C. Sudden onset of high fever
D. Twisting tongue movements
Answer: D. Twisting tongue movements
Rationale:
A. A shuffling gait, slowed movements, tremors, and drooling are manifestations of
antipsychotic-induced Parkinsonism. They are not findings in TD.
B. Akathisia is a feeling of inner restlessness which can begin within 2 months of treatment with
conventional antipsychotic medications. The client has difficulty remaining still and may tap his
feet or may pace constantly. Akathisia is not a finding in TD.
C. A sudden onset of high fever could indicate neuroleptic malignant syndrome, but is not a
finding in TD.

D. Twisting tongue movement, tics, sudden involuntary jerking movements of the extremities,
and other findings occur in TD. The nurse should notify the provider of these findings since
treatment includes reducing dosage of antipsychotic medications or perhaps changing to a
second-general antipsychotic medication.
237. A nurse reviews the laboratory report for a client who is receiving lithium three times daily
PO. The client's current blood lithium level is 1.8 mEq/L. The nurse identifies that this lab value
indicates which of the following?
A. A blood lithium level of 1.8 mEq/L is not within the maintenance treatment level.
B. The lithium level is at the toxic level.
C. The lithium level is below the therapeutic treatment level.
D. The lithium level is within the therapeutic level for initial treatment.
Answer: B. The lithium level is at the toxic level.
Rationale:
A. A blood lithium level greater than 1.5 mEq/L indicates toxicity. A therapeutic initial blood
level of lithium is 0.8 to 1.4 mEq/L. Blood levels for lithium maintenance should be between 0.4
and 1.3 mEq/L.
B. A blood lithium level greater than 1.5 mEq/L indicates toxicity. The nurse should monitor the
client for GI manifestations, coarse hand tremor, confusion, drowsiness, and should withhold the
lithium and notify the provider. A therapeutic initial blood level of lithium is 0.8 to 1.4 mEq/L.
Blood levels for lithium maintenance should be between 0.4 and 1.3 mEq/L.
C. A blood lithium level greater than 1.5 mEq/L indicates toxicity. A therapeutic initial blood
level of lithium is 0.8 to 1.4 mEq/L. Blood levels for lithium maintenance should be between 0.4
and 1.3 mEq/L.
D. A blood lithium level greater than 1.5 mEq/L indicates toxicity. A therapeutic initial blood
level of lithium is 0.8 to 1.4 mEq/L. Blood levels for lithium maintenance should be between 0.4
and 1.3 mEq/L.
238. A nurse is providing medication teaching for a client who has a new prescription for
phenelzine. Which of the following statements should the nurse include in the teaching?
A. "You should change positions slowly while taking this medication."

B. "This medication is prescribed to help overcome alcohol addiction."
C. "You should omit foods containing oxalates while taking phenalzine."
D. "You should avoid drinking liquids after your evening meal."
Answer: A. "You should change positions slowly while taking this medication."
Rationale:
A. Clients should change positions slowly while taking an MAOI due to the risk of orthostatic
hypotension. Light-headedness and fainting are common when taking phenelzine.
B. Phenelzine, a monoamine oxidase inhibitor (MAOI), is appropriate for the treatment of
depression and certain anxiety disorders rather than alcohol addiction.
C. Clients should avoid foods that contain tyramine rather than oxalates while taking a
monoamine oxidase inhibitor, such as phenelzine. Foods containing tyramine can interact with
phenelzine to cause severe hypertension.
D. Clients should avoid drinking liquids after the evening meal when taking diuretics. Phenelzine
can cause urinary hesitancy and the client should be advised to void just before taking the
medication and to notify the provider for an inability to void.
239. A nurse is caring for a client who is experiencing acute manifestations of withdrawal from
alcohol. Which of the following medications should the nurse expect to administer to the client?
A. Diazepam
B. Acamprosate
C. Naltrexone
D. Disulfiram
Answer: A. Diazepam
Rationale:
A. Diazepam, a benzodiazepine, is used to treat acute alcohol withdrawal. Diazepam helps to
decrease the intensity of withdrawal, prevent seizures, and helps to stabilize vital signs.
B. Acamprosate is a medication which helps manage and maintain abstinence in clients
following acute withdrawal. The nurse should not expect to administer acamprosate for a client
who is experiencing withdrawal from alcohol.

C. Acamprosate is a medication which helps manage and maintain abstinence in clients
following acute withdrawal. The nurse should not expect to administer acamprosate for a client
who is experiencing withdrawal from alcohol.
D. Disulfiram is a medication used to maintain alcohol abstinence in clients who have alcohol
use disorder. Disulfiram is not used to treat acute manifestations of withdrawal.
240. A nurse is assessing for the presence of extrapyramidal side effects (EPS) in a client who is
taking chlorpromazine. Which of the following findings should the nurse recognize as EPS?
(Select all that apply.)
A. Muscle spasms of the neck
B. Fidgeting behavior
C. Blurred vision
D. Tremors of the hands
E. Sexual dysfunction
Answer: A. Muscle spasms of the neck
B. Fidgeting behavior
D. Tremors of the hands
Rationale:
A. Muscle spasms of the neck is correct. Muscle spasms of the neck are an example of EPS
associated with conventional antipsychotics.
B. Fidgeting behavior is correct. Fidgeting behavior, or akathisia, consists of behaviors such as
pacing or fidgeting, which are distressing and uncomfortable for the client.
C. Blurred vision is incorrect. Blurred vision can occur when taking chlorpromazine and is an
anticholinergic manifestation, rather than an example of EPS.
D. Tremors of the hands is correct. Hand tremors are Parkinsonian manifestations which are part
of EPS.
E. Sexual dysfunction is incorrect. Sexual dysfunction is a potential adverse effect of
chlorpromazine, but it is not an EPS.

241. A nurse is teaching a client who has depression about a new prescription for fluoxetine 20
mg daily. Which of the following statements by the client indicates understanding of the
teaching?
A. "I should expect relief from depression within 3 to 4 days."
B. "I will take my fluoxetine at bedtime so I can sleep better."
C. "I should notify my provider if I develop a skin rash."
D. "I will notice an improvement in my sex drive."
Answer: C. "I should notify my provider if I develop a skin rash."
Rationale:
A. Antidepressant effects of Prozac begin in 1 to 4 weeks.
B. When it is prescribed once daily, the client should be advised to take fluoxetine in the morning
to prevent sleep disturbances, such as disturbing dreams.
C. Serious skin rashes, such as Stevens-Johnson syndrome, can occur while taking fluoxetine.
The client should notify the provider if a rash occurs.
D. Fluoxetine can cause sexual dysfunction, including decreased libido and menstrual changes in
women and impotence and decreased libido in men. The client should be encouraged to talk to
the provider if sexual dysfunction occurs, because there are strategies to minimize this adverse
effect such as decreasing the dosage.
242. A nurse is providing discharge teaching to a client with a new prescription for phenelzine.
The nurse should instruct the client to avoid which of the following foods when taking this
medication?
A. Salami
B. Cottage cheese
C. Shellfish
D. Frozen peas
Answer: A. Salami
Rationale:
A. Aged foods, such as hard cheeses and meats, salami, and air-dried sausage should be avoided
when taking an oral MAOI such as phenelzine.

B. Cottage cheese, cream cheese, and milk may be consumed when taking an MAOI such as
phenelzine.
C. Shellfish, such as shrimp or scallops, may be consumed when taking an MAOI such as
phenelzine, but smoked or pickled fish should be avoided.
D. With the exception of avocados and soybean paste, vegetables are safe to eat while taking
phenelzine.
243. A nurse in the emergency department is planning care for a client who is admitted for an
overdose of phencyclidine (PCP). Which of the following actions should the nurse plan to take?
A. Administer warmed IV fluids to counteract hypothermia.
B. Reverse the toxicity with naloxone.
C. Verbally attempt to calm the client.
D. Administer ammonium chloride.
Answer: D. Administer ammonium chloride.
Rationale:
A. High fever can occur as a result of PCP toxicity and the nurse should anticipate using external
cooling methods and administering dantrolene to reduce skeletal muscle contraction and
decrease temperature.
B. Naloxone reverses toxicity caused by opioids but is not useful for phencyclidine toxicity.
C. Due to drug-induced psychosis and risk for injury, the nurse should not attempt to verbally
calm the client.
D. Ammonium chloride acidifies the urine and promotes excretion of PCP. In addition, the nurse
should monitor the client's respiratory status and be prepared to assist with intubation and
mechanical ventilation.
244. A nurse is caring for a client who is in the manic phase of bipolar disorder. The client is
running around the unit trying to organize competitive games with the clients. Which of the
following is an appropriate intervention?
A. Recommend a game of table tennis with another client.
B. Suggest the client exercise on a stationary bike.
C. Take the client outside for a walk.

D. Praise the client’s efforts to engage in social interaction.
Answer: C. Take the client outside for a walk.
Rationale:
A. The nurse should choose a different activity for the client who is in the manic phase of bipolar
because the client may tend to over-engage in social interaction and physical activity
B. The nurse should recommend a less strenuous activity for the client.
C. Clients who are experiencing mania are at risk for physical exhaustion; therefore, the nurse
should redirect the client to a different activity that will decrease stimulation and slow the client’s
physical activity expenditure.
D. The nurse should recognize that clients who are experiencing mania are at risk for physical
exhaustion and tend to over-engage in social interaction.
245. A nurse is caring for a client who reports acute, moderate anxiety. Which of the following is
the priority nursing action?
A. Remain with the client.
B. Provide a diverting activity.
C. Encourage verbalization of feelings.
D. Instruct the client to remember past coping mechanisms.
Answer: A. Remain with the client.
Rationale:
A. The greatest risk to this client is self-injury from impulsive behavior; therefore, the nurse
should stay with the client to reduce anxiety and help the client feel safe.
B. The nurse should provide a diverting activity to provide the client with a way to relieve
tension; however, another action is the priority.
C. The nurse should encourage the client to verbalize her feelings to facilitate problem solving;
however, another action is the priority.
D. The nurse should instruct the client to remember past coping mechanisms to help the client
use personal strengths; however, another action is the priority.
246. A nurse is preparing a client who has chronic anxiety for discharge from the psychiatric
unit. Which of the following instructions should the nurse include in the client’s discharge plan?

A. Contact the crisis counselor once a week.
B. Identify anxiety-producing situations.
C. Try to repress feelings of anxiety.
D. Eliminate stress and anxiety from daily life.
Answer: B. Identify anxiety-producing situations.
Rationale:
A. The nurse should tell the client to contact a crisis counselor only in crisis situations, not on a
routine basis.
B. Treatment for anxiety disorders includes helping the client recognize signs that her anxiety
level is rising and the triggers that cause this type of reaction. The nurse should include this
information so the client can limit anxiety-provoking situations or intervene early to reduce
anxiety levels.
C. The nurse should encourage the client to continue to express feelings; repression of anxiety
leads to maladaptive behaviors.
D. It is not possible to eliminate stress and anxiety from daily life. Instead, the client should use
relaxation techniques such as deep breathing, exercise or listening to soft music.
247. A nurse is discussing the care of a client who has a conversion disorder with persistent
aphasia with a newly licensed nurse. Which of the following statements should the nurse include
about conversion disorder?
A. Conversion disorders are consciously triggered.
B. The condition may relapse within a year.
C. Testing for a pathophysiological cause of aphasia is not necessary.
D. Clients with conversion disorder have a flat affect.
Answer: B. The condition may relapse within a year.
Rationale:
A. The nurse should state that conversion disorders involve unconscious expression of mental
stress into physical symptoms.
B. About one-fourth of clients who have a conversion disorder will experience a relapse episode,
usually within a year after the initial occurrence.

C. The nurse should inform the newly licensed nurse that the provider should rule out any
physical cause as the first part of treating the client.
D. The nurse should inform the newly licensed nurse that clients who have a conversion disorder
are often very upset over loss of functioning.
248. A nurse is planning care for a client who is being treated for acute phencyclidine (PCP)
intoxication. Which of the following should the nurse include in the plan of care?
A. Engage the client in a physical diversion.
B. Monitor for hypertension.
C. Provide a warming blanket.
D. Maintain access to flumazenil.
Answer: B. Monitor for hypertension.
Rationale:
A. The nurse should plan to provide the client with a restful environment with low stimulation.
B. PCP intoxication can cause hypertension and tachycardia, as well as seizures and coma. The
nurse should monitor the client for elevated blood pressure and pulse and administer a
vasodilator, such as nitroprusside, as indicated.
C. The nurse should plan to monitor a client experiencing PCP intoxication for hyperthermia.
D. The nurse should plan to administer flumazenil for clients experiencing benzodiazepine
intoxication.
249. A nurse is caring for a client admitted to a mental health facility who asks, “Can I refuse the
electroconvulsive therapy (ECT) treatment scheduled for tomorrow?” Which of the following
should be the nurse’s response?
A. "You have given signed consent for the treatments after they were explained to you."
B. "You will feel better after the course of treatments."
C. "You can refuse them, but the provider believes they are necessary."
D. "You have the right to refuse even though the consent form has been signed."
Answer: D. "You have the right to refuse even though the consent form has been signed."
Rationale:

A. The tone of this statement may be threatening, and the client may perceive she is being
coerced and has no choice. The client has the right to withdraw consent after the consent form
has been signed.
B. The nurse has ignored the client’s question and has made a statement that may or may not be
true.
C. The client does have the right to refuse the treatment. The nurse is sending a subliminal
message attempting to persuade the client to follow the prescribed therapy.
D. Informed consent is a communication between provider and client regarding the risks and
benefits of treatment. The client authorizes the treatment with a witnessed signature to undergo
the medical intervention. The client has the right to refuse or delay treatment, even though the
informed consent has been signed.
250. A nurse is caring for a client who begins to yell and scream at staff members. Which of the
following should be the nurse’s priority action?
A. Administer haloperidol IM to the client.
B. Engage the client is an activity
C. Move the client to a seclusion room with continuous observation.
D. Say to the client, "I can tell that you are upset."
Answer: D. Say to the client, "I can tell that you are upset."
Rationale:
A. This medication would be considered a chemical restraint. A restraint is any manual method,
physical or mechanical device, material, or equipment that immobilizes or reduces the ability of
a client to move freely.
B. Attempting to engage the client in an activity ignores the client’s immediate behavior and
could be injurious to other clients and staff. An activity may take the client’s mind off his
concern, but is not the priority action.
C. Seclusion is involuntary confinement of a client alone in a room, or area from which the client
is physically prevented from leaving. Seclusion is used for the management of violent behavior
that jeopardizes the safety of the client and others. The nurse should first attempt other least
restrictive measures.

D. The nurse’s immediate priority when faced with a client who is potentially violent is to
maintain safety while preventing the behavior from escalating. This therapeutic communication
helps defuse anger and offers understanding and support. This statement demonstrates the nurse’s
desire to help the client while listening.