PNLE PSYCHIATRIC NURSING A. Paranoid thoughts 16.

A 39 year old mother with obsessive-compulsive disorder has

1. Marco approached Nurse Trish asking for advice on how to deal with B. Emotional affect become immobilized by her elaborate hand washing and walking rituals.
his alcohol addiction. Nurse Trish should tell the client that the only C. Independence need Nurse Trish recognizes that the basis of O.C. disorder is often:
effective treatment for alcoholism is: D. Aggressive behavior A. Problems with being too conscientious
A. Psychotherapy 9. Nurse Claire is caring for a client diagnosed with bulimia. The B. Problems with anger and remorse
B. Alcoholics anonymous (A.A.) most appropriate initial goal for a client diagnosed with bulimia is? C. Feelings of guilt and inadequacy
C. Total abstinence A. Encourage to avoid foods D. Feeling of unworthiness and hopelessness
D. Aversion Therapy B. Identify anxiety causing situations 17.Mario is complaining to other clients about not being allowed by staff
2. Nurse Hazel is caring for a male client who experience false C. Eat only three meals a day to keep food in his room. Which of the following interventions would be
sensory perceptions with no basis in reality. This perception is known as: D. Avoid shopping plenty of groceries most appropriate?
A. Hallucinations 10. Nurse Tony was caring for a 41 year old female client. Which A. Allowing a snack to be kept in his room
B. Delusions behavior by the client indicates adult cognitive development? B. Reprimanding the client
C. Loose associations A. Generates new levels of awareness C. Ignoring the clients behavior
D. Neologisms B. Assumes responsibility for her actions D. Setting limits on the behavior
3. Nurse Monet is caring for a female client who has suicidal C. Has maximum ability to solve problems and learn new 18.Conney with borderline personality disorder who is to be discharge
tendency. When accompanying the client to the restroom, Nurse Monet skills soon threatens to “do something” to herself if discharged. Which of the
should… D. Her perception are based on reality following actions by the nurse would be most important?
A. Give her privacy 11.A neuromuscular blocking agent is administered to a client before A. Ask a family member to stay with the client at home
B. Allow her to urinate ECT therapy. The Nurse should carefully observe the client for? temporarily
C. Open the window and allow her to get some fresh air A. Respiratory difficulties B. Discuss the meaning of the client’s statement with her
D. Observe her B. Nausea and vomiting C. Request an immediate extension for the client
4. Nurse Maureen is developing a plan of care for a female client C. Dizziness D. Ignore the clients statement because it’s a sign of
with anorexia nervosa. Which action should the nurse include in the D. Seizures manipulation
plan? 12.A 75 year old client is admitted to the hospital with the diagnosis 19.Joey a client with antisocial personality disorder belches loudly. A
A. Provide privacy during meals of dementia of the Alzheimer’s type and depression. The symptom that staff member asks Joey, “Do you know why people find you repulsive?”
B. Set-up a strict eating plan for the client is unrelated to depression would be? this statement most likely would elicit which of the following client
C. Encourage client to exercise to reduce anxiety A. Apathetic response to the environment reaction?
D. Restrict visits with the family B. “I don’t know” answer to questions A. Depensiveness
5. A client is experiencing anxiety attack. The most appropriate C. Shallow of labile effect B. Embarrassment
nursing intervention should include? D. Neglect of personal hygiene C. Shame
A. Turning on the television 13.Nurse Trish is working in a mental health facility; the nurse priority D. Remorsefulness
B. Leaving the client alone nursing intervention for a newly admitted client with bulimia nervosa 20.Which of the following approaches would be most appropriate to use
C. Staying with the client and speaking in short sentences would be to? with a client suffering from narcissistic personality disorder when
D. Ask the client to play with other clients A. Teach client to measure I & O discrepancies exist between what the client states and what actually
6. A female client is admitted with a diagnosis of delusions of B. Involve client in planning daily meal exist?
GRANDEUR. This diagnosis reflects a belief that one is: C. Observe client during meals A. Rationalization
A. Being Killed D. Monitor client continuously B. Supportive confrontation
B. Highly famous and important 14.Nurse Patricia is aware that the major health complication associated C. Limit setting
C. Responsible for evil world with intractable anorexia nervosa would be? D. Consistency
D. Connected to client unrelated to oneself A. Cardiac dysrhythmias resulting to cardiac arrest 21.Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis
7. A 20 year old client was diagnosed with dependent personality B. Glucose intolerance resulting in protracted hypoglycemia and hyperactivity. Blood pressure is 190/87 mmhg and pulse is 92 bpm.
disorder. Which behavior is not likely to be evidence of ineffective C. Endocrine imbalance causing cold amenorrhea Which of the medications would the nurse expect to administer?
individual coping? D. Decreased metabolism causing cold intolerance A. Naloxone (Narcan)
A. Recurrent self-destructive behavior 15.Nurse Anna can minimize agitation in a disturbed client by? B. Benzlropine (Cogentin)
B. Avoiding relationship A. Increasing stimulation C. Lorazepam (Ativan)
C. Showing interest in solitary activities B. limiting unnecessary interaction D. Haloperidol (Haldol)
D. Inability to make choices and decision without advise C. increasing appropriate sensory perception 22.Which of the following foods would the nurse Trish eliminate from
8. A male client is diagnosed with schizotypal personality disorder. D. ensuring constant client and staff contact the diet of a client in alcohol withdrawal?
Which signs would this client exhibit during social situation? A. Milk
 B. Orange Juice A. Displacement B. Routine Activities
C. Soda B. Projection C. Minimal decision making
D. Regular Coffee C. Sublimation D. Varied Activities
23.Which of the following would Nurse Hazel expect to assess for a D. Denial 37.To further assess a client’s suicidal potential. Nurse Katrina should
client who is exhibiting late signs of heroin withdrawal? 30.When working with a male client suffering phobia about black cats, be especially alert to the client expression of:
A. Yawning & diaphoresis Nurse Trish should anticipate that a problem for this client would be? A. Frustration & fear of death
B. Restlessness & Irritability A. Anxiety when discussing phobia B. Anger & resentment
C. Constipation & steatorrhea B. Anger toward the feared object C. Anxiety & loneliness
D. Vomiting and Diarrhea C. Denying that the phobia exist D. Helplessness & hopelessness
24.To establish open and trusting relationship with a female client who D. Distortion of reality when completing daily routines 38.A nursing care plan for a male client with bipolar I disorder should
has been hospitalized with severe anxiety, the nurse in charge should? 31.Linda is pacing the floor and appears extremely anxious. The duty include:
A. Encourage the staff to have frequent interaction with the nurse approaches in an attempt to alleviate Linda’s anxiety. The A. Providing a structured environment
client most therapeutic question by the nurse would be? B. Designing activities that will require the client to
B. Share an activity with the client A. Would you like to watch TV? maintain contact with reality
C. Give client feedback about behavior B. Would you like me to talk with you? C. Engaging the client in conversing about current affairs
D. Respect client’s need for personal space C. Are you feeling upset now? D. Touching the client provide assurance
25. Nurse Monette recognizes that the focus of environmental D. Ignore the client 39.When planning care for a female client using ritualistic behavior,
(MILIEU) therapy is to: 32.Nurse Penny is aware that the symptoms that distinguish post Nurse Gina must recognize that the ritual:
A. Manipulate the environment to bring about positive traumatic stress disorder from other anxiety disorder would be: A. Helps the client focus on the inability to deal with reality
changes in behavior A. Avoidance of situation & certain activities that resemble B. Helps the client control the anxiety
B. Allow the client’s freedom to determine whether or not the stress C. Is under the client’s conscious control
they will be involved in activities B. Depression and a blunted affect when discussing the D. Is used by the client primarily for secondary gains
C. Role play life events to meet individual needs traumatic situation 40.A 32 year old male graduate student, who has become
D. Use natural remedies rather than drugs to control C. Lack of interest in family & others increasingly withdrawn and neglectful of his work and personal hygiene,
behavior D. Re-experiencing the trauma in dreams or flashback is brought to the psychiatric hospital by his parents. After detailed
26.Nurse Trish would expect a child with a diagnosis of reactive 33.Nurse Benjie is communicating with a male client with substance- assessment, a diagnosis of schizophrenia is made. It is unlikely that the
attachment disorder to: induced persisting dementia; the client cannot remember facts and fills client will demonstrate:
A. Have more positive relation with the father than the in the gaps with imaginary information. Nurse Benjie is aware that this is A. Low self esteem
mother typical of? B. Concrete thinking
B. Cling to mother & cry on separation A. Flight of ideas C. Effective self boundaries
C. Be able to develop only superficial relation with the B. Associative looseness D. Weak ego
others C. Confabulation 41.A 23 year old client has been admitted with a diagnosis of
D. Have been physically abuse D. Concretism schizophrenia says to the nurse “Yes, its march, March is little woman”.
27.When teaching parents about childhood depression Nurse Trina 34.Nurse Joey is aware that the signs & symptoms that would be That’s literal you know”. These statement illustrate:
should say? most specific for diagnosis anorexia are? A. Neologisms
A. It may appear acting out behavior A. Excessive weight loss, amenorrhea & abdominal B. Echolalia
B. Does not respond to conventional treatment distension C. Flight of ideas
C. Is short in duration & resolves easily B. Slow pulse, 10% weight loss & alopecia D. Loosening of association
D. Looks almost identical to adult depression C. Compulsive behavior, excessive fears & nausea 42.A long term goal for a paranoid male client who has unjustifiably
28.Nurse Perry is aware that language development in autistic D. Excessive activity, memory lapses & an increased pulse accused his wife of having many extramarital affairs would be to help the
child resembles: 35.A characteristic that would suggest to Nurse Anne that an adolescent client develop:
A. Scanning speech may have bulimia would be: A. Insight into his behavior
B. Speech lag A. Frequent regurgitation & re-swallowing of food B. Better self control
C. Shuttering B. Previous history of gastritis C. Feeling of self worth
D. Echolalia C. Badly stained teeth D. Faith in his wife
29.A 60 year old female client who lives alone tells the nurse at D. Positive body image 43.A male client who is experiencing disordered thinking about food
the community health center “I really don’t need anyone to talk to”. The 36.Nurse Monette is aware that extremely depressed clients seem to do being poisoned is admitted to the mental health unit. The nurse uses
TV is my best friend. The nurse recognizes that the client is using the best in settings where they have: which communication technique to encourage the client to eat dinner?
defense mechanism known as? A. Multiple stimuli A. Focusing on self-disclosure of own food preference
 B. Using open ended question and silence 49.Nurse Tina is caring for a client with depression who has not expenditure, these electrolytes are necessary for cardiac
C. Offering opinion about the need to eat responded to antidepressant medication. The nurse anticipates that functioning.
D. Verbalizing reasons that the client may not choose to eat what treatment procedure may be prescribed. 15. B . Limiting unnecessary interaction will decrease stimulation and
44.Nurse Nina is assigned to care for a client diagnosed with A. Neuroleptic medication agitation.
Catatonic Stupor. When Nurse Nina enters the client’s room, the client is B. Short term seclusion 16. C . Ritualistic behavior seen in this disorder is aimed at controlling
found lying on the bed with a body pulled into a fetal position. Nurse C. Psychosurgery guilt and inadequacy by maintaining an absolute set pattern of
Nina should? D. Electroconvulsive therapy behavior.
A. Ask the client direct questions to encourage talking 50.Mario is admitted to the emergency room with drug-included 17. D . The nurse needs to set limits in the client’s manipulative
B. Rake the client into the dayroom to be with other clients anxiety related to over ingestion of prescribed antipsychotic medication. behavior to help the client control dysfunctional behavior. A
C. Sit beside the client in silence and occasionally ask open- The most important piece of information the nurse in charge should consistent approach by the staff is necessary to decrease
ended question obtain initially is the: manipulation.
D. Leave the client alone and continue with providing care A. Length of time on the med. 18. B . Any suicidal statement must be assessed by the nurse. The
to the other clients B. Name of the ingested medication & the amount ingested nurse should discuss the client’s statement with her to determine
45.Nurse Tina is caring for a client with delirium and states that “look at C. Reason for the suicide attempt its meaning in terms of suicide.
the spiders on the wall”. What should the nurse respond to the client? D. Name of the nearest relative & their phone number 19. A . When the staff member ask the client if he wonders why
A. “You’re having hallucination, there are no spiders in this Answers and Rationales others find him repulsive, the client is likely to feel defensive
room at all” 1. C . Total abstinence is the only effective treatment for alcoholism because the question is belittling. The natural tendency is to
B. “I can see the spiders on the wall, but they are not going 2. A . Hallucinations are visual, auditory, gustatory, tactile or counterattack the threat to self image.
to hurt you” olfactory perceptions that have no basis in reality. 20. B . The nurse would specifically use supportive confrontation
C. “Would you like me to kill the spiders” 3. D . The Nurse has a responsibility to observe continuously the with the client to point out discrepancies between what the
D. “I know you are frightened, but I do not see spiders on acutely suicidal client. The Nurse should watch for clues, such as client states and what actually exists to increase responsibility for
the wall” communicating suicidal thoughts, and messages; hoarding self.
46.Nurse Jonel is providing information to a community group about medications and talking about death. 21. C . The nurse would most likely administer benzodiazepine, such
violence in the family. Which statement by a group member would 4. B . Establishing a consistent eating plan and monitoring client’s as lorazepan (ativan) to the client who is experiencing symptom:
indicate a need to provide additional information? weight are important to this disorder. The client’s experiences symptoms of withdrawal because of the
A. “Abuse occurs more in low-income families” 5. C . Appropriate nursing interventions for an anxiety attack rebound phenomenon when the sedation of the CNS from
B. “Abuser Are often jealous or self-centered” include using short sentences, staying with the client, decreasing alcohol begins to decrease.
C. “Abuser use fear and intimidation” stimuli, remaining calm and medicating as needed. 22. D . Regular coffee contains caffeine which acts as psychomotor
D. “Abuser usually have poor self-esteem” 6. B . Delusion of grandeur is a false belief that one is highly famous stimulants and leads to feelings of anxiety and agitation. Serving
47.During electroconvulsive therapy (ECT) the client receives oxygen and important. coffee top the client may add to tremors or wakefulness.
by mask via positive pressure ventilation. The nurse assisting with 7. D . Individual with dependent personality disorder typically 23. D . Vomiting and diarrhea are usually the late signs of heroin
this procedure knows that positive pressure ventilation is necessary shows indecisiveness submissiveness and clinging behavior so withdrawal, along with muscle spasm, fever, nausea, repetitive,
because? that others will make decisions with them. abdominal cramps and backache.
A. Anesthesia is administered during the procedure 8. A . Clients with schizotypal personality disorder experience 24. D . Moving to a client’s personal space increases the feeling of
B. Decrease oxygen to the brain increases confusion excessive social anxiety that can lead to paranoid thoughts threat, which increases anxiety.
and disorientation 9. B . Bulimia disorder generally is a maladaptive coping response to 25. A . Environmental (MILIEU) therapy aims at having everything in
C. Grand mal seizure activity depresses respirations stress and underlying issues. The client should identify anxiety the client’s surrounding area toward helping the client.
D. Muscle relaxations given to prevent injury during seizure causing situation that stimulate the bulimic behavior and then 26. C . Children who have experienced attachment difficulties with
activity depress respirations. learn new ways of coping with the anxiety. primary caregiver are not able to trust others and therefore
48.When planning the discharge of a client with chronic anxiety, Nurse 10. A . An adult age 31 to 45 generates new level of awareness. relate superficially
Chris evaluates achievement of the discharge maintenance goals. Which 11. A . Neuromuscular Blocker, such as SUCCINYLCHOLINE 27. A . Children have difficulty verbally expressing their feelings,
goal would be most appropriately having been included in the plan of (Anectine) produces respiratory depression because it inhibits acting out behavior, such as temper tantrums, may indicate
care requiring evaluation? contractions of respiratory muscles. underlying depression.
A. The client eliminates all anxiety from daily situations 12. C . With depression, there is little or no emotional involvement 28. D . The autistic child repeat sounds or words spoken by others.
B. The client ignores feelings of anxiety therefore little alteration in affect. 29. D . The client statement is an example of the use of denial, a
C. The client identifies anxiety producing situations 13. D . These clients often hide food or force vomiting; therefore defense that blocks problem by unconscious refusing to admit
D. The client maintains contact with a crisis counselor they must be carefully monitored. they exist
14. A . These clients have severely depleted levels of sodium and 30. A . Discussion of the feared object triggers an emotional response
potassium because of their starvation diet and energy to the object.
31. B . The nurse presence may provide the client with support & 50. B . In an emergency, lives saving facts are obtained first. The
feeling of control. name and the amount of medication ingested are of outmost
32. D . Experiencing the actual trauma in dreams or flashback is the important in treating this potentially life threatening situation.
major symptom that distinguishes post traumatic stress disorder
from other anxiety disorder.
33. C . Confabulation or the filling in of memory gaps with imaginary
facts is a defense mechanism used by people experiencing
memory deficits.
34. A . These are the major signs of anorexia nervosa. Weight loss is
excessive (15% of expected weight)
35. C . Dental enamel erosion occurs from repeated self-induced
vomiting.
36. B . Depression usually is both emotional & physical. A simple daily
routine is the best, least stressful and least anxiety producing.
37. D . The expression of these feeling may indicate that this client is
unable to continue the struggle of life.
38. A . Structure tends to decrease agitation and anxiety and to
increase the client’s feeling of security.
39. B . The rituals used by a client with obsessive compulsive disorder
help control the anxiety level by maintaining a set pattern of
action.
40. C . A person with this disorder would not have adequate self-
boundaries
41. D . Loose associations are thoughts that are presented without
the logical connections usually necessary for the listening to
interpret the message.
42. C . Helping the client to develop feeling of self worth would
reduce the client’s need to use pathologic defenses.
43. B . Open ended questions and silence are strategies used to
encourage clients to discuss their problem in descriptive manner.
44. C . Clients who are withdrawn may be immobile and mute, and
require consistent, repeated interventions. Communication with
withdrawn clients requires much patience from the nurse. The
nurse facilitates communication with the client by sitting in
silence, asking open-ended question and pausing to provide
opportunities for the client to respond.
45. D . When hallucination is present, the nurse should reinforce
reality with the client.
46. A . Personal characteristics of abuser include low self-esteem,
immaturity, dependence, insecurity and jealousy.
47. D . A short acting skeletal muscle relaxant such as succinylcholine
(Anectine) is administered during this procedure to prevent
injuries during seizure.
48. C . Recognizing situations that produce anxiety allows the client
to prepare to cope with anxiety or avoid specific stimulus.
49. D . Electroconvulsive therapy is an effective treatment for
depression that has not responded to medication