PSYCHIA P1 6.

A nurse who is directly responsible for providing

care to an individual client such as administering
SAS 1 medication or teaching a life skill is performing which
vital role of the mental health nurse?
1. A mental health nurse who exercises supervision
A. Case Manager C. Care Provider
over other nurses in providing coordination of care to
B. Researcher D. Patient Advocate
a client diagnosed with a mental disorder is
performing which particular role? Rationale: A nurse is a caregiver for patients
and helps to manage physical needs, prevent
A. Researcher C. Case Manager
illness, and treat health conditions.
B. Care Provider D. Patient Advocate

Rationale: The nurse directs and coordinates

7. The nurse advises a client to join yoga classes as a
care by both professionals and
method to relieve stress would be fulfilling the
nonprofessionals to confirm that a patient's
function of:
goals are being met
2. The nurse is teaching a client important life skills A. Health Teaching C. Milieu Therapy
that can be useful around the house when he leaves B. Counselling D. Psychotherapy
the mental health facility. The nurse is performing
which function? Rationale: Counselling - intervention and
communication techniques, problem solving,
A. Case Management C. Self - Care Activities stress management, behavior modification,crisis
B. Counselling D. Milieu Therapy intervention
Rationale: Self - Care Activities - encourage
independence, increase self - esteem, improve
function and health
8. When a client presents at the Emergency Room
3. An individual who prefers to be alone and isolated
with peculiar behaviors and a strong desire for self -
may be at risk for mental disorders because which
harm, the diagnosis of the specific mental disorder of
factor affecting mental health is impaired?
that client will have to be based on:
A. Interpersonal factors C. Family factors
A. Client verbalization C. Client history
B. Social - cultural factors D. Individual factors B. Client behavior D. Criteria from DSM V
Rationale: Interpersonal - effective Rationale: DSMV is a taxonomic and diagnostic
communication, ability to help others, intimacy, tool developed by the American Psychiatric
connectedness, separateness Association used internationally as a principal
authority for psychiatric diagnoses.
4. According to the American Psychiatric Association,
which is not a a possible cause of mental disorder:

A. Death of a parent C. Rape 9. Extreme poverty pushes a man to depression. This

B. Loss of a limb D. A complete family phenomenon is an example of which factor exerting
an influence on mental health:
Rationale: Defined by the American Psychiatric
Association as a clinical significant behavioral or A. Individual C. Interpersonal
psychological syndrome or pattern that occurs in
B. Social - cultural D. Financial
an individual and is associated with present
distress such as a painful symptom, a disability, Rationale: Social - cultural - sense of community,
increased risk of suffering death, pain or a loss of access to adequate resources, intolerance to
freedom. violence, support of diversity among people,
5. According to the World Health Organization, health positive yet realistic view of one’s world, poverty
involves wellness of the following human aspects,
EXCEPT: 10. The nurse responsible for administering
medications to a client admitted with a mental
A. Physical C. Social
B. Mental D. Economic disorder is performing which function?
Rationale: Health is a state of complete A. Care Provider C. Psychologic Interventions
physical, mental and social well-being and not
merely the absence of disease or infirmity . B. Psychotherapy D.Case Manager
Rationale: Psychologic Interventions - administer
medications, teaching, client observation
 C. Managed Care
SAS 2 B.Deinstitutionalization

1. The development of an initial system to classify D. Primary Care

mental illness through its symptoms was first
Rationale: Deinstitutionalization: release of
developed by:
individuals from state institutions, diversion from
A.Eugene Bleuler C. Emil Kraepelin hospitalizationand development of alternative
community services
B.Hildegard Peplau D. Sigmund Freud 7. In the current century, mental illness among the
population has been made worse due to which social
Rationale: Kraepelin began classifying mental issue: A.Unemployment C. Substance Abuse
disorders according to their symptoms
2. Dorothea Dix emphasized that all the following B.Poverty D. Stress
should be provided by an asylum EXCEPT: Rationale: Many people have dual problems of
mental illness and substance abuse. Use of
A.Proper Medication C. Adequate Shelter alcohol and drugs exacerbates symptoms of
mental illness
B.Nutritious Food D. Warm Clothing
8. This organization began the requirement for related
Rationale: In the United States, Dorothea Dix, learning experience in the psychiatric setting for
began a campaign to reform the treatment of students:
mental illness leading to theopening of 32 state
hospitals that offered asylum which promoted A.American Nurses Association
adequate shelter, nutritious food and warm
clothing C. National League for Nursing
3. In the 1950’s, this was the first medication B.International Council of Nursing
developed to treat mania: D. America Psychiatric Nursing Association
Rationale: In 1950 the National League for Nursing
A.Chlorpromazine C. Haloperidol
required schools to include an experience in
B.Lithium D. Sertraline
psychiatric nursing
Rationale: Chlorpromazine (Thorazine), an
antipsychotic drug and lithium, an antimanic drug
were developed first
4. In the late 1700’s this facility was developed to 9. During the ancient times, persons with mental
provide a safe environment for people with mental illness who exhibited behaviors that harm others were:
illness: A.Asylum C. Mental Hospital
A.Hospitalized C. Imprisoned
B.Sanitarium D. State Hospital
B.Worshipped D. Prayed For
Rationale: In the 1790’s Phillippe Pinel in France
and William Tukes formulated the concept of Rationale: those who were violent were thrown in
asylum, as a refuge or havenfor those with mental prison and starved
illness, this began the movement for moral
treatment of mental illness 10. This book emphasized that the treatment of
persons with mental illness should focus on
5. Aristotle theorized that the imbalance of 4 elements psychosocial strengths and needs:
caused mental illness EXCEPT which one:
A.Mental Health Nursing Management
A.Food C. Yellow Bile
C. Interpersonal Relations in Nursing
B.Blood D. Water
Rationale: Aristotle theorized that water, blood, B. Nursing Therapy
yellow bile and black bile controlled one’s D. Interpersonal Techniques: The Crux of Psychiatric
emotions. Imbalances between the 4 caused Nursing
mental illness Rationale: Mellow’s 1968 work Nursing Therapy
described the approach of focusing on the client’s
6. This refers to the practice of reducing emphasis on
mental health care from inpatient facilities to psychosocial strengthsand needs which suited those
community treatment centers: with severe mental illness
A. Sanitarium
SAS 3
 Rationale: Oral- Birth to 18 Months -Major site of
1. The personality structures: Id, Superego and Ego tension or gratification is the mouth, lips, tongue,
were described by which theorist: includes biting and sucking activities, Id present
at birth, Ego starts to develop gradually
A.Erik Erikson C. Jean Piaget
6. Under Maslow’s Hierarchy of Needs, an individual
B.Sigmund Freud D. Hildegard Peplau who at work has not fulfilled/achieve which stage?
Rationale: Freud theorized that a personality is
composed of the ID (basic desires such as A.Love and Belongingness C. Physiologic Needs
pleasure seeking, aggression and sexual
impulses), the SUPEREGO (the person’s moral and B.Self – Actualization D. Esteem Needs
ethical concepts, values and expectation) and the
EGO (adaptive behaviour and balancing between 7. An individual who has decided to marry his/her
the ID and SUPEREGO). partner has achieved which focus under the
Psychosocial Theory:
2. Under Eriksons’s Psychosocial Theory, an
individual who expresses a sense of satisfaction with A.Intimacy vs. Isolation
his decisions and actions in life is under which stage?
C. Generativity vs. Isolation
A. Intimacy vs. Isolation
C. Ego Integrity vs. Despair B. Identity vs. Role Confusion
B. Trust vs. Mistrust D. Initiative vs. Guilt D. Autonomy vs. Shame and Doubt
Rationale: Intimacy vs. Isolation (Young Adult)-
Rationale: Ego Integrity vs. Despair (Old Love - Forming adult loving relationships and
Age/Maturity) - Wisdom - Accepting meaningful attachments to others
responsibility for one’s actions done
throughout life
8. Toilet training children is performed at this stage of
the Psychosexual Theory:
3. This theory indicated that sexuality and sexual
energy play a major factor in how an individual acts A.Latent Stage C. Anal Stage
and behaves towards others and the environment: B. Genital Stage D. Phallic Stage
A. Psychosexual Theory Rationale: Anal- 18 – 26 Months Anus and
C. Expressive Sexuality Theory surrounding area are major source of interest,
B. Hierarchy of Needs acquisition of voluntary sphincter control, toilet
D. Psychosocial Theory training is started
Rationale: The theory supports the notion that all
human behaviour is caused and can be explained.
9. Under the Hierarchy of Needs, a person deprived of
Sexual impulses and desires motivate human
a home and suffers from poverty will not be able to
behaviour.
progress to which next stage?
4. A child proudly displays to his mother the good
marks he obtained during activities while in school. A.Safety and Security Needs
Based on Erikson’s Psychosocial Theory, which stage C. Love and Belongingness
is the child in? B. Self – Actualization
D. Esteem Needs
A.Industry vs. Inferiority C. Trust vs. Mistrust Rationale: Physiologic Needs include food, water,
sleep, shelter, sexual expression and freedom
B. Initiative vs. Guilt from pain, the next stage is Safety and Security
D. Autonomy vs. Shame and Doubt Needs - protection, security, freedom from harm,
Rationale: Industry vs. Inferiority (School Age)-
Competence-Emerging confidence in own abilities,
taking pleasure in accomplishments
10. A child who begins to build a group of friends in
school and around the neighborhood is now under
5. An adult who engages in nail biting behaviors which cognitive stage of development?
during stressful situations may have unresolved
issues during which stage of psychosexual A.Preoperational Stage
engagement?
C. Concrete Operations Stage
A.Phallic Stage C. Oral Stage
B.Formal Operations Stage
B. Latency Stage D. Genital Stage
 D. Sensorimotor Stage A.Mild Anxiety C. Panic Anxiety

Rationale: Preoperational-2 – 6 Years- Develops the B. Severe Anxiety D. Moderate Anxiety

ability express self through language,
Understands the meaning of symbolic gestures, Rationale: Mild Anxiety – a positive state of
Begins to classify objects heightened awareness and sharpened senses
allowing the person to learn new behaviors and
solve problems while taking all available stimuli
SAS 4
6. A rape victim who suddenly loses her vision a few
1 .A nurse advising a client about yoga as a method of seconds after seeing her rapist on street is
stress relief is performing which role according to experiencing which level of anxiety?
Peplau’s Theory?
A. Mild Anxiety C. Panic Anxiety
A. Teacher C. Resource Person
B. Severe Anxiety D. Moderate Anxiety
B. Counselor D. Leader Rationale: Panic Anxiety – the person losses
rational thought, begins to experience
Rationale Resource Person – the nurse provides hallucinations, delusions, muteness and in some
specific answers to questions of a general context cases physical immobility or hyperactivity, the
regarding the client’s condition person may run aimlessly exposing him/herself to
danger
2. Mutually developing goals for the client’s care is under
which phase of the Therapeutic Nurse – Patient 7. When the nurse and client review the progress that
Relationship? they have made in terms of therapy and attainment of
goals this already falls under which phase of the
A. Resolution C. Exploitation Therapeutic Nurse – Patient Relationship
B. Identification D. Orientation
Rationale: Orientation Phase – directed by the A. Exploitation C. Identification
nurse and involves the engaging the client in B. Orientation. D. Resolution
treatment, providing explanation and information
as well as answering questions Rationale: Resolution Phase – the client no longer
needs professional services from the nurse and
gives up dependent behaviors which signals the
3. A nurse who begins communicating to a new client end of the relationship
admitted in the facility is performing which role under
Peplau’s Theory?
8. The nurse who takers a supervisory function in client
A.Stranger C. Resource Person care management is performing which role according
to Peplau?
B.Leader D. Surrogate
A. Leader C. Teacher
Rationale: Stranger – the nurse offers the client B. Surrogate D. Counselor
the same acceptance and courtesy as the nurse Rationale: Leader – the nurse offers direction to
would to any stranger the client or a group of clients

9. A woman begins experiencing a tightness of the

4. When nurse assists the client to develop a positive chest and mild difficulty or breathing while attending
self – concept and coping, this situation occurs under the court case of her husband in likely experiencing
which phase of the Therapeutic Nurse – Patient which level of anxiety?
Relationship?
A. Mild Anxiety C. Moderate Anxiety
A. Orientation C. Exploitation
B. Severe Anxiety D. Panic Anxiety
B. Identification D. Resolution
Rationale: Identification Phase – begins when the Rationale: Severe Anxiety – involves feelings of
client begins working together with the nurse, dread or terror, the person focuses only on
expresses his/her feelings and begins to feel scattered details, cannot be redirected to a task
better/stronger and has physiologic symptoms such as
tachycardia, diaphoresis and chest pain, they may
5. An individual who is able to cope effectively in a feel they are having a heart attack because of
stressful situation is experiencing which level of these symptoms
anxiety only?
 which theindividual believes he/she is being
10. Peplau saw the primary role of the nurse in the treated maliciously; This situation reflects this
Therapeutic Nurse – Patient Relationship as: type of delusion

A. Leader – Manager 3. Patient Rodney states “I am the president of the

C. Participant - Observer Philippines!” This statement indicates what type of
B. Teacher – Surrogate delusion?
D. Counselor – Adviser A. Ideas of reference
B. Paranoid
Rationale: A Nursing theorist and clinician who saw the C. Grandiose
role of the nurse as a participant – observer within the D. Nihilistic
relationship dynamic between the nurse and the Rationale: Grandiose - they believe they are
greater, more influential than who they are
patient. The nurse is a participant in the planning and
provision of care and an observer during the entire
nursing process.
4. Patient Betty currently admitted to a mental health
facility. While joining an art therapy session, the
SAS 5 patient suddenly laughed out aloud ran to a corner
an began crying. As the nurse on duty, you would
1. The nurse is talking to a client. The client abruptly recognize this affect as:
says to the nurse, “The moon is full. Astronauts
A. Labile
walk on the moon. Walking is a good health habit.”
The client’s behavior most likely indicates: B. Blunt
A. Flight of Ideas
C. Flat
B. Neologisms
D. Inappropriate
C. Dissociation
Rationale: Labile Effect - rapid, unpredictable
D. Word Salad changes in affect
Rationale: Though the client's statements are
not typical of logical communication, the 5. The nurse is conducting an ongoing assessment
second and third remark contain elements of of a client with schizophrenia. While performing
the preceding sentence (moon, walk). the interview, the client suddenly stood up from
Neologisms refers to making up words that the chair and began running around calling out the
have personal meaning to the client. Flight of name of his wife. The nurse interprets this as the
ideas defines nearly continuous flow of client having a:
speech, jumping from one unconnected topic
to another. Word salad refers to stringing A. Tactile Hallucination
together real words into nonsense B. Kinesthetic Hallucination
"sentences" that have no meaning for the C. Auditory Hallucination
listener. D. Visual Hallucination
Rationale: Visual - seeing things that do not
exist or aren't there
2. A client on an in-patient psychiatric ward refuses
to take medications because, “The pill has a 6. When in an assessment interview a client
special code written on it that will make it suddenly stops talking, opens his mouth and
poisonous.” What kind of delusion is the client walks to a corner, this disturbance in the thought
experiencing? process in interpreted by the nurse as:

A. An erotomanic delusion A. Racing

B. Obsessional
C. A somatic delusion C. Loose
D. Blocked
B. A persecutory delusion Rationale: Blocked - stops speaking suddenly
and without explanation
D. A grandiose delusion

Rationale: A persecutory delusion is one in

 7. Nurse Elwood notices that his client who is in bed Rationale: The magnetic fields in MRI scanners can
has one arm raised and one leg flexed for over an cause five dangerous interactions in patients with
hour interprets this to indicate that the client has/is metallic foreign bodies: projectile effect, twisting,
in: burning, artifacts, and device malfunction
(interference with a pacemaker). Therefore, all
A. Psychomotor Retardation patients need to thoroughly be screened
C. Hallucinations individually for foreign bodies before undergoing
B. Waxy Flexibility an MRI scan.

D. Automatisms 2. An important point of patient education for those

undergoing a CT Scan should be:
Rationale: Waxy Flexibility - maintenance of
posture or position over time even when it is A. Stay still while undergoing the procedure
awkward or uncomfortable C. Change positions constantly while undergoing the
procedure
8. When the nurse asks the client what he would B. The patient can move if he/she is uncomfortable
have wanted to change in his life, the nurse is
assessing for: D. The patient can sit up on bed when he/she needs
to
A. Self – Concept
C. Thought Process Rationale: The person undergoing a CT scan must
B. Judgment lie motionless on a stretcher-like table for about
D. Orientation 20 to 40 minutes as the stretcher passes through
Rationale: Self - Concept - the way the client a “ring” while the serial x-rays are taken
views his/her personal worth and dignity

3. During this test, a client is required is perform brain

– stimulating activities such as reading while brain
9. Being able to change one’s behavior and functioning activity is being monitored:
decisions based on sound interpretation of the
situation is: A.PET/SPECT C. CT Scan

A. Thought Content C. Insight B.MRI D. Photon Scan

B. Mood D. Judgment Rationale: Positron Emission Tomography (PET)
and Single Photon Emission Computed
Rationale: Ability to interpret one's Tomography (SPECT), are used to examine the
environment and situation correctly to adapt function of the brain. Radioactive substances are
to one's behavior and decisions accordingly injected into the blood; the flow of those
substances in the brain is monitored as the client
performs cognitive activities such as reading as
instructed by the operator.
10. A client admitted at the mental health facility, has
been shouting out aloud claiming that he is the
4. Through a CT Scan, the ventricles in the brain of a
one true god is likely undergoing an:
patient diagnosed with this mental illness/disorder
A. Grandiose Delusion is enlarged:

C. Somatic Delusion A. Schizophrenia C. Anxiety Disorder

B. Bipolar Disorder D. Eating Disorders
B. Religious Delusion
D. Nihilistic Delusion Rationale: Some people with schizophrenia have
Rationale: Grandiose - they believe they are greater, been shown to have enlarged ventricles trough a
CT scan
more influential than who they are

SAS 6 5. When administering radioactive dye for a patient

about to undergo a PET/SPECT, the nurse must
monitor for:
1. A nurse preparing a psychiatric client for a
Magnetic Resonance Imaging procedure check that A.Mania C. Allergic reaction
that the client does not have any:
B.Depression D. Anxiety
A. Special Medications C. Dentures Rationale: It’s possible to have an allergic reaction
B. Tight fitting clothes D. Rubber bracelet to the radioactive dye or tracer. People who are
allergic to iodine, aspartame, or saccharin should are diagnosed with this mental illness/disorder
alert their doctor. exhibited reduced cortical thickness in the brain:

A. Anxiety C. Schizophrenia
6. A patient who suddenly becomes restless and
B. Depression D. Mania
anxious while undergoing an MRI may be
experiencing: Rationale: Selemon and Goldman - Rakic (1995) found
a 7% reduction in cortical thickness in persons with
A. Agoraphobia
schizophrenia.
C. Arachnophobia
B.Claustrophobia
D. Autophobia SAS 7
Rationale: Claustrophobia is a situational phobia
triggered by an irrational and intense fear of tight
or crowded spaces. 1. A nurse who is able adequately determine what the
client is feeling through listening from the client and
sensing the true meaning of the client’s words is
practicing which component of therapeutic
7. This diagnostic procedure is ideal if there is a need
relationship?
to produce a clearer picture of brain tissues and
blood flow: A. Empathy C. Positive Regard
B. Self – Awareness D. Genuine Interest
A. CT Scan C. Photon Scan
Rationale: Empathy - the ability of the nurse to
B. PET/SPECT D. MRI
perceive the meanings and feelings of the client
Rationale: Magnetic Resonance Imaging (MRI), a and to comunicate that understanding to the client
type of body scan, an energy field is created with
a huge magnet and radio waves. The energy field
is converted to a visual image or scan. MRI 2. This refers to a nurse’s personal set of standards
produces more tissue detail and contrast than CT about what is right and wrong when dealing with the
and can show blood flow patterns and tissue client or other members of the healthcare team is:
changes such as edema.
A. Beliefs C. Values
B. Attitudes D. Self – awareness
8. This procedure uses a continuous flow of x – ray
beams to take layered images of the brain: Rationale: Values - are abstract standards that give
a person a sense of right and wrong and establish
A. Photon Scan C. CT Scan a code of conduct for living
B. MRI D. PET/SPECT
3. When the nurse who aims to build trust with the
Rationale: Computed tomography (CT, also called
client is conscious about his/her words being
computed axial tomography or CAT scan) is a
translated into action is practicing?
procedure in which a precise x-ray beam takes
cross-sectional images (slices) layer by layer. A A. Positive Regard C. Attitudes
computer reconstructs the images on a monitor
and also stores the images on magnetic tape or B. Congruence D. Acceptance
film Rationale: Congruence - occurs when words said
by the nurse or client match with teir actions, this
builds trust
9. Patients who are known to suffer from anxiety
issues but need to undergo an MRI will need to be: 4. The nurse who patiently cares for his/her client and
does not judge the client based on displayed
A.Sedated C. Undergo therapy
behaviors is displaying which important component of
B. Hypnotized D. Restrained the therapeutic relationship?

Rationale: The person undergoing an MRI must lie A. Trust C. Positive Regard
in a small, closed chamber and remain motionless B. Genuine Interest D. Acceptance
during the procedure, which takes about 45 Rationale: Acceptance - the nurse who does not
minutes. Those who feel claustrophobic or have become upset or respond negatively to a client's
increased anxiety may require sedation before the outburst, anger, or acting empathy vs sympathy
procedure.

5. When a nurse caring for a client with a mental

10. An MRI has determined that some patients who
illness/disorder has a good grasp of his/her own 10. Effective therapeutic use of self can only be
attitude, values, beliefs and feelings, the nurse has achieved when the nurse has:
achieved:
A. Empathy C. Positive Regard
A.Self – awareness C. Acceptance B. Self – awareness D. Genuine Interest
Rationale: Therapeutic use of self is achieved
B. Trust D. Genuine Interest by developing self awareness and beginning
Rationale: Self Awareness- the process of to understand his/her own attitudes, the
developing an understanding of one's own values, nurse can begin to use aspects of his/her
beliefs, thoughts, feelings, attitudes, motivations, personality, experiences, values, feelings,
prejudices, strengths, and limitations and how intelligence, needs, coping skills, and
these qualities affect others perceptions to establish relationships with
clients
6. These are ideas that the nurse holds to be true
SAS 8
when caring for the client with a mental
illness/disorder:
1. When a nurse asks the client questions that seek
A. Attitudes C. Values to go deeper into a particular topic or idea is utilizing
B. Beliefs D. Self – awareness which therapeutic communication technique:

Rationale: Beliefs - are ideas that one holds to be A. Exploring C. Restating

true
B. General Leads D. Seeking Information
Rationale: Exploring—delving subject or idea
further into a subject or idea ― When clients deal
7. A nurse who displays actions that are inconsistent with topics superficially, exploring can help them
with his/her words and display unexpected behaviors examine the issue more fully. Any problem or
is not able to build: concern can be better understood if explored in
depth. If the client expresses an unwillingness to
A. Positive Regard C. Self - awareness
explore a subject, however, the nurse must respect
B. Genuine Interest D. Trust his or her wishes.
Rationale: Incongruent behaviors, prevent
building trust or reduces trust between the 2. Which therapeutic communication technique is
nurse and client being used in this nurse-client interaction? Client:
―When I am anxious, the only thing that calms me
8. Effective therapeutic use of self by the nurse down is alcohol.‖
requires that the nurse must be:
Nurse: ―Other than drinking, what alternatives have
A. Capable of complete assessment you explored to decrease anxiety?‖
C. Responds to the client according to the client’s A. Reflecting
needs C. Making observations
B. Knowledgeable on psychopharmacology B. Formulating a plan of action
D. Expert in psychotherapy
D. Giving recognition
Rationale: Therapeutic use of self respond to your
client in the way they need it, not in the way you Rationale: Formulating a plan of action—asking the
think they need it client to consider kinds of behavior likely to be
appropriate in future situations -- It may be helpful
for the client to plan in advance what he or she
9. Appreciating the client as a person who has specific might do in future similar situations. Making
needs and worthy of respect is displaying which definite plans increases the likelihood that the
component? client will cope more
A. Positive Regard C. Trust effectively in a similar situation.
B. Genuine Interest D. Empathy Answer:

Rationale: Positive Regard - The nurse who 3. Nurse Patrick is interviewing a newly admitted
appreciate the client as unique, worthwhile human psychiatric client. Which nursing statement is an
being, can respect the client regardless his/her example of offering a
behavior, background or lifestyle
―general lead‖?
A.―Do you know why you are here?‖ client
B.―Are you feeling depressed or anxious?‖ C.Sitting squarely, facing the client
D.Maintaining open posture with arms and legs
C.―Yes, I see. Go on.‖ crossed
D.―Can you chronologically order the events that led to Rationale: The nurse indicates interest in and
your admission?‖ acceptance of the client by facing and slightly
Rationale: General leads—giving encouragement to leaning toward him or her while maintaining
continue (Go on.‖ ―And then?‖ ―Tell me nonthreatening eye contact
about it.‖) -- General leads indicate that the nurse
is listening and following what the client is saying
7. These are long pauses that a client may be prone
without taking away the initiative for the
to exhibiting when lost in his/her own thoughts or
interaction. They also encourage the client to
trying to remember them:
continue if he or she is hesitant or uncomfortable
about the topic. A.Body Language C.Silence

B.Posture D.Eye Contact

4. A client diagnosed with post-traumatic stress Rationale: Silence or long pauses in
disorder is admitted to an inpatient psychiatric unit for communication may indicate many different
evaluation and medication stabilization. Which things. The client may be depressed and
therapeutic communication technique used by the struggling to find the energy to talk. Sometimes
nurse is an example of a broad opening? pauses indicate the client is thoughtfully
considering the question before responding. At
A.―What occurred prior to the rape, and when did you times, the client may seem to be ―lost in his or her
go to the emergency department?‖ own thoughts‖ and not paying attention to the
nurse. It is important to allow the client sufficient
B.―What would you like to talk about?‖ time to respond.
C.―I notice you seem uncomfortable discussing this.‖
D.―How can we help you feel safe during your stay
here?‖
8. When the nurse asks the client to make a brief
Rationale: Broad openings—allowing the client to
comparison of his/her actions, the therapeutic
take the initiative in introducing the topic (―Is
technique being employed is:
there something you’d like to talk about?‖
―Where would you like to begin? ‖) Broad A.Giving Recognition C.Offering Self
openings make explicit that the client has the lead B.Encouraging Comparison D.Restating
in the interaction. For the client who is hesitant Rationale: Encouraging comparison— asking that
about talking, broad openings may stimulate him similarities and differences be noted-- Comparing
or her to take the initiative. ideas, experiences, or relationships brings out
many recurring themes. The client benefits from
5. A nurse is assessing a client diagnosed with making these comparisons because he or she
schizophrenia for the presence of hallucinations. might recall past coping strategies that were
Which therapeutic communication technique used by effective or remember that he or she has survived
the nurse is an example of making observations? a similar situation

A.―You appear to be talking to someone I do not see.‖

9. Nurse Elwood who is carefully watching and noting
B.―Please describe what you are seeing.‖ the client’s body language is utilizing:
C.―Why do you continually look in the corner of this
room?‖ A.Touch C. Active Observation

D.―If you hum a tune, the voices may not be so B.Active Listening D. Respecting Boundaries
distracting.‖ Rationale: Active Observation - watching the
Rationale: Making observations— verbalizing what speaker’s nonverbal actions as he or she
the nurse perceives― Sometimes clients cannot communicates
verbalize or make themselves understood. Or the
client may not be ready to talk. 10. When formulating goals of care for the client with a
mental illness/disorder, these must be:
6. When interviewing a client, which nonverbal
behavior should a nurse employ? A.Nurse – centered C. Client-centered

A. Maintaining indirect eye contact with the client B.Nurse manager – centered D. Family-centered

B. Providing space by leaning back away from the Rationale: Goals of Therapeutic Communication
include Identifying the most important client client to talk about things he does not want to talk
concern at that moment (the client-centered goal). about. This is an example of:

A. Nurse – Client Contracts C. Establishing Rapport

SAS 9
B. Confidentiality D. Self – disclosure
1. During the course of the interaction, the nurse Rationale: Confidentiality - respecting the client’s
shares to the client that they have the same favorite right to keep private any information about his or
color and food to establish a closer working her mental and physical health and related care.
relationship between the two of them. This is an
example of the use of:
5. The nurse is listening attentively to the client to
A. Nurse – Client Contracts C. Self - disclosure ensure proper assessment and begin building rapport
between the two of them is performing a task in which
B. Establishing Rapport D. Maintaining the phase:
relationship
Rationale: Self – disclosure - revealing personal A. Termination Phase C. Working - Exploitation
information such as biographical information and B. Working – Problem Identification
personal ideas, thoughts, and feelings about D. Orientation Phase
oneself to clients, improves rapport between the Rationale: Working – Problem Identification
nurse and client but the nurse must be careful include: Maintains separate identity; Exhibits
with providing his/her own personal information ability to edit speech or control focal attention •
and must give this some thought Shows unconditional acceptance • Helps express
needs, feelings • Assesses and adjusts to needs •
Provides information • Provides experiences that
2. A client shows resistance to the nurse during the diminish feelings of helplessness • Does not allow
interaction due to past negative experience with anxiety to overwhelm client • Helps client focus on
another nurse. The client ignores the nurse during the cues • Helps client develop responses to cues •
interaction and does not participate in therapy. This Uses word stimuli
phenomenon is known as:

A. Countertransference
C. Poor Therapeutic Communication 6. A client who has become more open and warmer
B. Transference when communicating with the nurse is now in which
D. Lack of Rapport phase:
Rationale: Transference – the client unconsciously
transfers to the nurse the feelings he/she has for A. Orientation Phase
others
C. Working - Exploitation

B. Termination Phase
C. D. Working – Problem Identification
3. When the client begins to show positive self – Rationale: Working- Exploitation include: Makes
regard, this phase has already been reached: full use of services • Identifies new goals •
Attempts to attain new goals • Rapid shifts in
A. Termination C. Orientation behavior: dependent, independent • Exploitative
B. Working – Problem Identification behavior • Self-directing • Develops skill in
D. Working – Exploitation interpersonal relationships and problem-solving •
Rationale: Client has reached Termination phase Displays changes in manner of communication
when he/she Abandons old needs; Aspires to new (more open, flexible)
goals; Becomes independent of helping person;
Applies new problem solving skills; Maintains
changes in style of communication and
7. The nurse who is reviewing the client’s medical
interaction; Shows positive changes in view of
history and list of medications is performing tasks in
self ; Integrates illness ; Exhibits ability to stand
which phase:
alone
A. Working – Exploitation
C. Termination Phase
4. Nurse Angelo has started working on building a B. Orientation Phase
therapeutic relationship with an identified client.
During the course of the initial interaction, the client D. Working – Problem Identification
states that he is not comfortable talking about his line Rationale: During orientation phase, Before
of work. Nurse Angelo replies that he will not force the
meeting the client, the nurse has important work
to do. The nurse reads background materials 1. The nurse conducting an interview and recording all
available on the client, becomes familiar with any information obtained from the interaction with the
medications the client is taking, gathers client must first meet the important requisite of:
necessary paperwork, and arranges for a quiet,
private, comfortable setting. A. Confidentiality C. Training
B. Consent D. Privacy
Rationale: Consent must be obtained prior to the
interaction. If the nurse decides to record the
8. When Nurse Elwood outlines to his client his conversation, this must be included in the
specific responsibilities during the initial phases of consent;
therapeutic relationship, he is performing:

A. Nurse – Client Contract

2. Which of the following is not included in the process
C. Establishing Rapport recording of an interaction between the nurse and
the client:
B. Self – disclosure
D. Observing Confidentiality A. Client’s Behaviors C. Nurse’s Beliefs
Rationale: Nurse – Client Contracts – outlines the B. Client’s Movements D. Nurse’s Actions
responsibilities of the nurse and client, it should Rationale: All except option C is included in the
state the time, place and length of sessions, the process recording of an interaction between the
timeframe, the treatment plan and those involved nurse and the client
as well as specific responsibilities of both parties

9. The client who is able to link certain stressors which 3. Throughout the entire interaction, the conversation
are causing to his problematic behaviors is now in between the nurse and client must be held in a quiet,
which phase: calm environment to ensure:
A. Working – Problem Identification A. Privacy C. Comfort of the Nurse
C. Orientation Phase B. Availability of Information D. Nurse’s Preference
B. Working – Exploitation
D. Termination Phase Rationale: The nurse must carefully select an area
Rationale: Client has reached Termination phase which provides privacy, is quiet and calm
when he/she Abandons old needs; Aspires to new
goals; Becomes independent of helping person;
Applies new problem solving skills; Maintains
changes in style of communication and 4. Mental Health Process Recording must be done:
interaction; Shows positive changes in view of
self ; Integrates illness ; Exhibits ability to stand A. Within the shift
alone C. Immediately after the interaction
B. Several hours after the interaction
D. During patient handover
10. Expectation setting between the nurse and client Rationale: The process recording should be done
occurs in which phase of the therapeutic as soon as possible after the interview so that the
relationship: recording will be as accurate and complete as
possible;
A. Termination Phase

C. Working – Problem Identification 5. A complete recording of the entire interaction

between the nurse and client including the client’s
B. Working – Exploitation words, actions and peculiar behaviors:
D. Orientation Phase
Rationale: During the orientation phase, the A. Hospital Chart C. Verbatim Record
nurse establishes roles, the purpose of B. Process Recording D. Nurse’s Notes
meeting, and the parameters of subsequent Rationale: In the mental health process recording ,
meetings; identifies the client’s problems; all the client’s verbalizations and actions during
and clarifies expectations. the interaction with the nurse is recorded;

SAS 10 SAS 11
 suppression that occurs in some children.
1. The nurse is teaching a client taking an MAOI
about foods with tyramine that he or she should avoid.
5. The nurse is caring for a client with schizophrenia
Which of the following statements indicates that the
who is taking haloperidol (Haldol). The client
client needs further teaching?
complains of restlessness, cannot sit still, and has
A. “I’m so glad I can have pizza as long as I don’t muscle stiffness. Of the following prn medications,
order pepperoni.” which would the nurse administer?
B. “I will be able to eat cottage cheese without
A. Haloperidol (Haldol) 5 mg p.o.
worrying.”
B. Benztropine (Cogentin) 2 mg p.o.
C. “I will have to avoid drinking nonalcoholic beer.”
D. “I can eat green beans on this diet.” C. Propranolol (Inderal) 20 mg p.o.
Rationale: No Tyramine rich foods for those taking D. Trazodone 50 mg p.o.
MAOI - aged meats (pepperoni, salami), cheese, Rationale: Extrapyramidal Side effects of anti
beer, yogurt, avocado (to prevent hypertension, psychotics include Akathisia - restless, anxious,
tachycardia, cardiac dysrhythmias) agitated – Treatment is Beta - blocker, Cogentin,
Benzodiazepine
2. A client who has been depressed and suicidal
started taking a tricyclic antidepressant 2 weeks ago
and is now ready to leave the hospital to go home.
Which of the following is a concern for the nurse as
discharge plans are finalized? 6. Client teaching for lamotrigine (Lamictal) should
include which of the following?
A. The client may need a prescription for
diphenhydramine (Benadryl) to use for side effects. A. Eat a well balanced diet to avoid weight gain.
B. The nurse will evaluate the risk for suicide by B. Report any rashes to your doctor immediately.
overdose of the tricyclic antidepressant. C. Take each dose with food to avoid nausea.

C. The nurse will need to include teaching regarding D. This drug may cause psychological dependence.
the signs of neuroleptic malignant syndrome. Rationale: lamotrigine (Lamictal) can cause
D. The client will need regular laboratory work to serious rashes requiring hospitalization, including
monitor therapeutic drug levels. Stevens-Johnson syndrome and, rarely, life-
threatening toxic epidermal necrolysis. The risk
Rationale: The client is still at risk to commit for serious rashes is greater in children younger
suicide if given a chance, it is still important to than 16 year
monitor the client for the possible risks

7. Which of the following physician orders would the

3. The signs of lithium toxicity include which of the nurse question for a client who has stated “I’m allergic
following? to phenothiazines?”

A. Sedation, fever, restlessness A. Haldol 5 mg p.o. bid

B. Psychomotor agitation, insomnia, increased thirst B. Navane 10 mg p.o. bid
C. Elevated WBC count, sweating, confusion C. Prolixin 5 mg p.o.tid

D. Severe vomiting, diarrhea, weakness D. Risperdal 2 mg bid

Rationale: Phenothiazines are examples of
Rationale: toxic effects of lithium are severe antipsychotics: Mellaril, Thorazine
diarrhea, vomiting, drowsiness, muscle weakness,
and lack of coordination.
8. Clients taking which of the following types of
psychotropic medications need close monitoring of
their cardiac status?
4. Which of the following is a concern for children A. Antidepressants B. Antipsychotics
taking stimulants for ADHD for several years? C. Mood stabilizers D. Stimulants
Rationale: May lengthen the QT interval, leading to
A. Dependence on the drug C. Growth suppression
potentially life-threatening cardiac dysrhythmias
B. Insomnia D. Weight Gain
or cardiac arrest.
Rationale: The most common long-term problem
with stimulants is the growth and weight
9. What is the major side effect of Selective Serotonin treatment. This nursing reply acknowledges this
Reuptake Inhibitor (Prozac)? right but focuses on the client's concerns so that
the nurse can provide needed information
A. Loss of sexual desire C. Loss of hair
B. Weight loss D. Weight gain
3. Immediately after an initial electroconvulsive
Rationale: SSRI side effects include weight gain, therapy (ECT) treatment a client states, "I'm not
anxiety, agitation, akathisia, insomnia, sexual hungry and just want to stay in bed and sleep." Based
dysfunction, sedation, hand tremors, but the on this information, which is the most appropriate
major side effect of Selective Serotonin Reuptake nursing intervention?
Inhibitor (Prozac) is Loss of sexual desire A. Allow the client to remain in bed.
B. Encourage the client to join the milieu to promote
10. Antipsychotics do which of the following? socialization.
C. Obtain a physician's order for parenteral nutrition.
A. Alleviate major positive symptoms (such as thought
disorder and hallucinations) D. Involve the client in physical activities to stimulate
B. Alleviate major negative symptoms (such as social circulation.
withdrawal)
C. Reducing the burden of institutional care Rationale: Immediately after electroconvulsive
therapy a nurse should monitor pulse,
D. All of the above respirations, and blood pressure every 15 minutes
for the first hour, during which time the client
Rationale: Antipsychotic Drugs : Drug treatments should remain in bed
intended to treat symptoms of psychosis and
schizophrenia

SAS 12 4. A nurse administers ordered preoperative

glycopyrrolate (Robinul) 30 minutes prior to a client's
1. A nursing instructor is teaching about electroconvulsive therapy (ECT) treatment. What is
Electroconvulsive therapy to students. Which the rationale for administering this medication?
response by the students indicates that learning has
A. Robinul decreases anxiety during the ECT
occurred?
procedure.
A. “During ECT, a state if euphoria is induced.” B. Robinul induces an unconscious state to prevent
pain during the ECT procedure.
B. “ECT induces a grand mal seizure.”
C. Robinul prevents severe muscle contractions
C. “During ECT a state of catatonia is induced.” during the ECT procedure.
D. “ECT induces a petit mal seizure.” D. Robinul decreases secretions to prevent aspiration
Rationale: Electroconvulsive therapy is the during the ECT procedure.
induction of a grand mal seizure through the
application of electrical current to the brain for the Rationale: Glycopyrrolate (Robinul) is the standard
purpose of decreasing depression preoperative medication given prior to ECT
treatments to decrease secretions and prevent
aspiration.
2. After receiving two of nine electroconvulsive
therapy (ECT) treatments, a client states, "I can't even
remember eating breakfast, so I want to stop the ECT
treatments." Which is the most appropriate nursing
5. A nursing instructor is teaching about the
reply?
medications given prior to and during
A. "After you begin the course of treatments, you must electroconvulsive therapy (ECT) treatments. Which
complete all of them." student statement indicates that learning has
occurred?
B. "You'll need to talk with your doctor about what
A. "Atropine (Atro-Pen) is administered to paralyze
you're thinking."
skeletal muscles during ECT."
C. "It is within your right to discontinue the treatments,
B. "Succinylcholine chloride (Anectine) decreases
but let's talk about your concerns."
secretions to prevent aspiration."
D. "Memory loss is a rare side effect of the treatment.
C. "Thiopental sodium (Pentothal) is a short-acting
I don't think it should be a concern."
Rationale: The client has the right to terminate anesthesia to render the client unconscious."
D. "Glycopyrrolate (Robinul) is given to prevent severe Electroconvulsive Therapy is:
muscle contractions during seizure."
A. Retrograde Amnesia
Rationale: In order to render a client unconscious B. Fractures
during the ECT procedure, an anesthesiologist
administers intravenously, a short-acting C. Seizures
anesthetic like thiopental sodium (Pentothal). D. Hypertension
Rationale: Memory Loss – some clients develop
retrograde amnesia (trouble remembering
6. Immediately after electroconvulsive therapy, in memories before treatment), these problems
which position should a nurse place the client? usually resolve within a few months after
completion of therapy
A. On his or her side to prevent aspiration
B. In semi-Fowler's position to promote oxygenation
10.The most common indication of Electroconvulsive
C. In Trendelenburg's position to promote blood flow Therapy is:
to vital organs
D. In prone position to prevent airway blockage A. Schizophrenia
Rationale: The nurse should place a client who has B. Generalized Anxiety Disorder
received electroconvulsive therapy on his or her C. Manic episodes
side to prevent aspiration. After the treatment,
most clients will awaken within 10 to 15 minutes D. Major Depression
and will be confused and disoriented. Some
clients will sleep for 1 to 2 hours. All clients Rationale: Severe depression, treatment
require close observation following treatment. resistant depression, treatment resistant mania
or catatonia. are indications of ECT but the
7. After receiving two of nine electroconvulsive most common is Depression
therapy (ECT) treatments, a client states, "I can't even
remember eating breakfast, so I want to stop the ECT
treatments." Which is the most appropriate nursing SAS 13
reply?
1. The nurse is planning to utilize bibliotherapy for a
A. "After you begin the course of treatments, you must client with a mild mood – related condition. The nurse
complete all of them." selects a few books regarding yoga and stress –
B. "You'll need to talk with your doctor about what relief. This type of bibliotherapy is called:
you're thinking."
A. Creative Bibliotherapy
C. "It is within your right to discontinue the treatments, C. Prescriptive Bibliotherapy
but let's talk about your concerns." B. Books on Prescription
D. "Memory loss is a rare side effect of the treatment. D. General Bibliotherapy
I don't think it should be a concern." Rationale: books on Prescription is a program
where reading materials targeting specific mental
Rationale: The client has the right to terminate health needs are "prescribed" by mental health
treatment. This nursing reply acknowledges this professionals.
right but focuses on the client's concerns so that
the nurse can provide needed information.
2. A form of group therapy which uses the family as
a therapeutic tool for the client the dynamics of
8. What is considered as the gold standard for his/her psychopathology and develop problem –
confirmation of seizure in ECT? A.Cuff method solving skills as a group.
B. Electroencephalogram (EEG) A. Milieu Therapy
C. Electromyogram (EMG) C. Remotivation Therapy
B. Family Therapy
D. Galvanic Skin Response (GSR)
Rationale: An Electroencephalogram (EEG) is used D. Music Therapy
throughout the procedure to record electrical
activity in the brain including episodes of Rationale: Family Therapy is a form of group
seizures. therapy in which the client and his or her family
members participate. The goals include
understanding how family dynamics contribute to
the client’s psychopathology, mobilizing the
9. The most persistent adverse effect of family’s inherent strengths and functional
resources, restructuring maladaptive family French. This treatment approach may be known
behavioral styles, and strengthening family as milieu therapy (MT) because those in the
problem-solving behaviors program are immersed in a small, structured
community focused on helping them develop
3. During this stage of Remotivation Therapy, the skills and behaviors that’ll enable them to live
nurse asks the client questions which are about the healthier lives in a larger society.
relatedness of the current therapy session to life:
2. A nurse therapists brings the child who has just
A. Appreciation of the Work of the World experienced physical abuse to a playground and
allows the child to freely play with all the different toys
C. Climate of Acceptance with only limited instruction is using which type of play
therapy:
B. Climate of Appreciation
D. Bridge to the Real World A. Directive Play Therapy
Rationale: Appreciation of the Work of the World –
this step involves life – related questions based C. Nondirective Play Therapy
from the poem/story/song
B. Single Directional Play Therapy
D. Multi - Nondirectional Play Therapy
4. A kind of therapy which features a therapist Rationale: Nondirective Play Therapy - based on
allowing the client to express him/herself through the principle that children can resolve their own
singing, composing songs or just listening to them. issues given the right conditions and the freedom
to play with limited instruction and supervision
A. Song Therapy C. Dance Therapy
B. Music Therapy D. Sound Therapy 3. This type of therapy allows the client to express
Rationale: Music Therapy is an established health him/herself through creativity and creative works
profession in which music is used within a which are helpful for those with suffering from intense
therapeutic relationship to address physical, trauma:
emotional, cognitive, and social needs of
A.Art Therapy C. Music Therapy
individuals. After assessing the strengths and
B. Play Therapy D. Psychospiritual Therapy
needs of each client, the qualified music therapist
provides the indicated treatment including Rationale: art therapy allows people to express
creating, singing, moving to, and/or listening to feelings on any subject through creative work
music. rather than with speech, it is believed to be
particularly helpful for those who feel out of touch
5. A nurse selected a teenage novel for the
with their emotions or feelings. Individuals
bibliotherapy of an adolescent with a mild depression.
experiencing difficulty discussing or remembering
This type of bibliotherapy is:
painful experiences may also find art therapy
A. Creative Bibliotherapy especially beneficial.
C. Prescriptive Bibliotherapy
4. When the nurse therapist choose a specific set of
B. Books on Prescription
play things to elicit a desired response from a
D. General Bibliotherapy traumatized child is using which type of play therapy:

Rationale: Creative bibliotherapy utilizes A. Directive Play Therapy

imaginative literature—novels, short stories,
poetry, plays, and biographies—to improve C. Nondirective Play Therapy
psychological well-being.
B. Single Directional Play Therapy
D. Multi - Nondirectional Play Therapy
SAS 14 Rationale: Directive Play Therapy - uses more
input from the therapist to help speed up results
1. A client is placed in a structured facility with a small such as choosing particular toys or kinds of plays
number of patients and provided therapy designed to
5. This therapy involves simultaneously engaging
develop life skills and functional behavior. This therapy
the body, mind, and spirit in healing mental health
is:
issues, moving beyond problematic life patterns, and
A. Art Therapy C. Remotivation Therapy overcoming traumatic life experiences:
B. Milieu Therapy D. Adult Play Therapy
A. Milieu Therapy
Rationale: Milieu therapy is a method for treating C. Art Therapy
mental health conditions using a person’s B. Play Therapy
surroundings to encourage healthier ways of D. Psychospiritual Therapy
thinking and behaving.“Milieu” means “middle” in Rationale: Psychospiritual therapy involves
simultaneously engaging the body, mind, and B. Moderate Anxiety D. Panic Anxiety
spirit in healing mental health issues, moving Rationale: Moderate Anxiety – a disturbing feeling
beyond problematic life patterns, and overcoming that something is definitely wrong, the person
traumatic life experiences. Typically, the patient becomes nervous or agitated, has difficulty
will be guided into utilizing their symptoms or concentrating but can still be redirected to the
difficult season of life as a catalyst for topic; Manifestations are selectively attentive,
psychospiritual transformation. cannot connect thoughts, muscle tension,
diaphoresis, headache, frequent urination, dry
mouth, high pitch voice
SAS 15 3. Which of the following would be the best
intervention for a client having a panic attack?
1. While caring for a male client with a mental illness,
the nurse notices that the client has suddenly become A. Involve the client in a physical activity.
quiet after seeing a physician walk by with a syringe, C. Remain with the client.
the client then becomes agitated, is not responsive to B. Offer a distraction such as music.
the nurse and runs to a corner of his room and hide in D. Teach the client a relaxation technique
fear. Based on the nurse’s assessment, the client is in Rationale: In Panic Anxiety - safety is primary
which level of anxiety? concern, keep talking to client in a comforting
manner, proceed to a small quiet non - stimulating
A. Moderate Anxiety C. Panic Anxiety environment, reassure that it is only anxiety,
B. Severe Anxiety D. Mild Anxiety remain with the client until panic recedes (5 - 30
Rationale: Panic Anxiety - the most severe level, minutes)
the person has no coherent thought;
Manifestations are cannot process environmental
4. When assessing a client with anxiety, the nurse’s
stimuli, distorted perceptions, no verbal
questions should be:
communication, delusions or hallucinations,
suicidal, may bolt or run (flight), totally immobile A. Avoided until the anxiety is gone
(freeze) or become mute C. Postponed until the client volunteers information
B. Open-ended
2. The nurse observes a client who is becoming
increasingly upset. He is rapidly pacing, D. Specific and direct
hyperventilating, clenching his jaw, wringing his
hands, and trembling. His speech is high-pitched and Rationale: Ensure that client follows your
random; he seems preoccupied with his thoughts. He instructions, refocus client with calm imagery,
is pounding his fist into his other hand. The nurse speak in short, simple, easy to understand
identifies his anxiety level as: sentences, assess client continuously if he/she
understand your instructions
A. Mild Anxiety C. Severe Anxiety

5. A client resorting to fantasizing and delusion during an anxious event is experiencing which type of adaptive
behavior:

A. Negative Adaptive Behaviors

C. Delusional Adaptive Behaviors
B. Positive Adaptive Behaviors
D. Panic Adaptive Behaviors
Rationale: Negative Adaptive Behaviors - result in maladaptive behaviors such as tension headaches, pain
syndromes, and stress-related responses that reduce the efficiency of the immune system

6. Which of the following is an appropriate intervention for a client experiencing a severe anxiety:
A. Teach relaxation techniques
C. Confining the client to the room
B. Walk with client if he/she is restless and agitated
D. Offer the client a distraction such as music
Rationale: In managing Severe Anxiety - lower client's anxiety level (ensure safety and grounding), remain with
the client, talk in calm, low voice, if restless walk with the client while talking
7. This type of anxiety allows the person to build health coping skills and engage in goal – oriented activities:
A. Panic Anxiety C. Moderate Anxiety
B. Severe Anxiety D. Mild Anxiety
Rationale: Mild Anxiety - - a sensation that something is different orneeds special attention, this type motivates
people to make changes or engage in goal - directed activity
8. During this stage of the response stress, the client begins to exhibit agitation, clenching of the fist and anger:
A. Exhaustion Stage C. Resistance Stage
B. Alarm Stage D. General Anxious Stage
Rationale: Exhaustion Stage –occurs when the body has a negative response to anxiety and stress, body stores
(glucose, adrenaline) are used up and emotional components are not resolved, results in continuous arousal of
the physiologic response
9. Refocusing the client who is experiencing a moderate anxiety can be achieved through:
A. Guided imagery C. Restraining the client
B. Physical activity D. Confining the client to his room
Rationale: In Moderate Anxiety - ensure that client follows your instructions, refocus client with calm imagery,
speak in short, simple, easy to understand sentences, assess client continuously if he/she understand your
instructions
10. An anxious client who is able to use deep breathing and relaxation techniques has:
A. Negative Adaptive Behaviors C. Acceptable Adaptive Behaviors
B. Positive Adaptive Behaviors D. Positive Coping
Rationale: Positive Adaptive Behaviors - help the person to learn: for example, using imagery techniques to
refocus attention on a pleasant scene, practicing sequential relaxation of the body from head to toe, and
breathing slowly and steadily to reduce muscle tension and vital signs .