Psychiatric Nursing Practice Test I

October 26, 2009 By admin 4 Comments

1. Which nursing intervention is best for facilitating communication with a

psychiatric client who speaks a foreign language?

a. Rely on nonverbal communication.

b. Select symbolic pictures as aids.

c. Speak in universal phrases.

d. Use the services of an interpreter.

2. The nurse explains to a mental health care technician that a client’s

obsessive-compulsive behaviors are related to unconscious conflict
between id impulses and the superego (or conscience). On which of the
following theories does the nurse base this statement?

a. Behavioral theory

b. Cognitive theory

c. Interpersonal theory

d. Psychoanalytic theory

3. The nurse observes a client pacing in the hall. Which statement by the nurse
may help the client recognize his anxiety?

a. “I guess you’re worried about something, aren’t you?

b. “Can I get you some medication to help calm you?”

c. “Have you been pacing for a long time?”

d. “I notice that you’re pacing. How are you feeling?”

4. A client with obsessive-compulsive disorder is hospitalized on an inpatient

unit. Which nursing response is most therapeutic?

a. Accepting the client’s obsessive-compulsive behaviors

b. Challenging the client’s obsessive-compulsive behaviors

c. Preventing the client’s obsessive-compulsive behaviors

d. Rejecting the client’s obsessive-compulsive behaviors

5. A 45-year-old woman with a history of depression tells a nurse in her
doctor’s office that she has difficulty with sexual arousal and is fearful that
her husband will have an affair. Which of the following factors would the
nurse identify as least significant in contributing to the client’s sexual
difficulty?

a. Education and work history

b. Medication used

c. Physical health status

d. Quality of spousal relationship

6. Which nursing intervention is most appropriate for a client with anorexia

nervosa during initial hospitalization on a behavioral therapy unit?

a. Emphasize the importance of good nutrition to establish normal weight.

b. Ignore the client’s mealtime behavior and focus instead on issues of

dependence and independence.

c. Help establish a plan using privileges and restrictions based on

compliance with refeeding.

d. Teach the client information about the long-term physical consequence

of anorexia.

7. A nurse is evaluating therapy with the family of a client with anorexia

nervosa. Which of the following would indicate that the therapy was
successful?

a. The parents reinforce increased decision making by the client.

b. The parents clearly verbalize their expectations for the client.

c. The client verbalizes that family meals are now enjoyable.

d. The client tells her parents about feelings of low-self-esteem.

8. The nurse is working with a client with a somatoform disorder. Which client
outcome goal would the nurse most likely establish in this situation?

a. The client will recognize signs and symptoms of physical illness.

b. The client will cope with physical illness.

c. The client will take prescribed medications.

 d. The client will express anxiety verbally rather than through physical
symptoms.

9. Which method would a nurse use to determine a client’s potential risk for
suicide?

a. Wait for the client to bring up the subject of suicide.

b. Observe the client’s behavior for cues of suicide ideation.

c. Question the client directly about suicidal thoughts.

d. Question the client about future plans.

10. A client with a bipolar disorder exhibits manic behavior. The nursing
diagnosis is Disturbed thought processes related to difficulty
concentrating, secondary to flight of ideas. Which of the following
outcome criteria would indicate improvement in the client?

a. The client verbalizes feelings directly during treatment.

b. The client verbalizes positive “self” statement.

c. The client speaks in coherent sentences.

d. The client reports feelings calmer.

11. A client tells a nurse. “Everyone would be better off if I wasn’t alive.”
Which nursing diagnosis would be made based on this statement?

a. Disturbed thought processes

b. Ineffective coping

c. Risk for self-directed violence

d. Impaired social interaction

12. Which information is most essential in the initial teaching session for the
family of a young adult recently diagnosed with schizophrenia?

a. Symptoms of this disease imbalance in the brain.

b. Genetic history is an important factor related to the development of

schizophrenia.

c. Schizophrenia is a serious disease affecting every aspect of a person’s

functioning.
 d. The distressing symptoms of this disorder can respond to treatment with
medications.

13. A nurse is working with a client who has schizophrenia, paranoid type.
Which of the following outcomes related to the client’s delusional
perceptions would the nurse establish?

a. The client will demonstrate realistic interpretation of daily events in the

unit.

b. The client will perform daily hygiene and grooming without assistance.

c. The client will take prescribed medications without difficulty.

d. The client will participate in unit activities.

14. A client with bipolar disorder, manic type, exhibits extreme excitement,
delusional thinking, and command hallucinations. Which of the following
is the priority nursing diagnosis?

a. Anxiety

b. Impaired social interaction

c. Disturbed sensory-perceptual alteration (auditory)

d. Risk for other-directed violence

15. A client who abuses alcohol and cocaine tells a nurse that he only uses
substances because of his stressful marriage and difficult job. Which
defense mechanisms is this client using?

a. Displacement

b. Projection

c. Rationalization

d. Sublimation

16. An 11-year-old child diagnosed with conduct disorder is admitted to the

psychiatric unit for treatment. Which of the following behaviors would the
nurse assess?

a. Restlessness, short attention span, hyperactivity

b. Physical aggressiveness, low stress tolerance disregard for the rights of

others
 c. Deterioration in social functioning, excessive anxiety and worry, bizarre
behavior

d. Sadness, poor appetite and sleeplessness, loss of interest in activities

17. The nurse understands that if a client continues to be dependent on heroin

throughout her pregnancy, her baby will be at high risk for:

a. Mental retardation.

b. Heroin dependence.

c. Addiction in adulthood.

d. Psychological disturbances.

18. The emergency department nurse is assigned to provide care for a victim
of a sexual assault. When following legal and agency guidelines, which
intervention is most important?

a. Determine the assailant’s identity.

b. Preserve the client’s privacy.

c. Identify the extent of injury.

d. Ensure an unbroken chain of evidence.

19. Which factor is least important in the decision regarding whether a victim
of family violence can safely remain in the home?

a. The availability of appropriate community shelters

b. The nonabusing caretaker’s ability to intervene on the client’s behalf

c. The client’s possible response to relocation

d. The family’s socioeconomic status

20. The nurse would expect a client with early Alzheimer’s disease to have
problems with:

a. Balancing a checkbook.

b. Self-care measures.

c. Relating to family members.

d. Remembering his own name

21. Which nursing intervention is most appropriate for a client with
Alzheimer’s disease who has frequent episodes emotional lability?

a. Attempt humor to alter the client mood.

b. Explore reasons for the client’s altered mood.

c. Reduce environmental stimuli to redirect the client’s attention.

d. Use logic to point out reality aspects.

22. Which neurotransmitter has been implicated in the development of

Alzheimer’s disease?

a. Acetylcholine

b. Dopamine

c. Epinephrine

d. Serotonin

23. Which factors are most essential for the nurse to assess when providing
crisis intervention foe a client?

a. The client’s communication and coping skills

b. The client’s anxiety level and ability to express feelings

c. The client’s perception of the triggering event and availability of

situational supports

d. The client’s use of reality testing and level of depression

24. The nurse considers a client’s response to crisis intervention successful if

the client:

a. Changes coping skills and behavioral patterns.

b. Develops insight into reasons why the crisis occurred.

c. Learns to relate better to others.

d. Returns to his previous level of functioning.

25. Two nurses are co-leading group therapy for seven clients in the
psychiatric unit. The leaders observe that the group members are anxious
and look to the leaders for answers. Which phase of development is this
group in?
 a. Conflict resolution phase

b. Initiation phase

c. Working phase

d. Termination phase

26. Group members have worked very hard, and the nurse reminds them that
termination is approaching. Termination is considered successful if group
members:

a. Decide to continue.

b. Elevate group progress

c. Focus on positive experience

d. Stop attending prior to termination.

27. The nurse is teaching a group of clients about the mood-stabilizing

medications lithium carbonate. Which medications should she instruct the
clients to avoid because of the increased risk of lithium toxicity?

a. Antacids

b. Antibiotics

c. Diuretics

d. Hypoglycemic agents

28. When providing family therapy, the nurse analyzes the functioning of
healthy family systems. Which situations would not increase stress on a
healthy family system?

a. An adolescent’s going away to college

b. The birth of a child

c. The death of a grandparent

d. Parental disagreement

29. A client taking the monoamine oxidase inhibitor (MAOI) antidepressant

isocarboxazid (Marplan) is instructed by the nurse to avoid which foods
and beverages?

a. Aged cheese and red wine

 b. Milk and green, leaf vegetables

c. Carbonated beverages and tomato products

d. Lean red meats and fruit juices

30. Prior to administering chlorpromazine (Thorazine) to an agitated client, the

nurse should:

a. Assess skin color and sclera

b. Assess the radial pulse

c. Take the client’s blood pressure

d. Ask the client to void

31. The nurse understands that electroconvulsive therapy is primary used in

psychiatric care for the treatment of:

a. Anxiety disorders.

b. Depression.

c. Mania.

d. Schizophrenia.

32. A client taking the MAOI phenelzine (Nardil) tells the nurse that he
routinely takes all of the medications listed below. Which medication
would cause the nurse to express concern and therefore initiate further
teaching?

a. Acetaminophen (Tylenol)

b. Diphenhydramine (Benadryl)

c. Furosemide (Lasix)

d. Isosorbide dinitrate (Isordil)

33. The nurse is administering a psychotropic drug to an elderly client who has
history of benign prostatic hypertrophy. It is most important for the nurse
to teach this client to:

a. Add fiber to his diet.

b. Exercise on a regular basis.

c. Report incomplete bladder emptying

 d. Take the prescribed dose at bedtime.

34. The nurse correctly teaches a client taking the benzodiazepine oxazepam
(Serax) to avoid excessive intake of:

a. Cheese

b. Coffee

c. Sugar

d. Shellfish

35. The nurse provides a referral to Alcoholics Anonymous to a client who

describes a 20-year history of alcohol abuse. The primary function of this
group is to:

a. Encourage the use of a 12-step program.

b. Help members maintain sobriety.

c. Provide fellowship among members.

d. Teach positive coping mechanisms.

36. Which client outcome is most appropriately achieved in a community

approach setting in psychiatric nursing?

a. The client performs activities of daily living and learns about crafts.

b. The client’s is able to prevent aggressive behavior and monitors his use
of medications.

c. The client demonstrates self-reliance and social adaptation.

d. The client experience experiences anxiety relief and learns about his
symptoms.

37. A client with panic disorder experiences an acute attack while the nurse is
completing an admission assessment. List the following interventions
according to their level of priority.

a. Remain with the client.

b. Encourage physical activity.

c. Encourage low, deep breathing.

d. Reduce external stimuli.

 e. Teach coping measures.

38. The doctor has prescribed haloperidol (Haldol) 2.5 mg. I.M. for an agitated
client. The medication is labeled haloperidol 10 mg/2 ml. The nurse
prepares the correct dose by drawing up how many milliliters in the
syringe?

a. 0.3

b. 0.4

c. 0.5

d. 0.6

39. The nurse enters the room of a client with a cognitive impairment disorder
and asks what day of the week it is: what the date, month, and year are;
and where the client is. The nurse is attempting to assess:

a. Confabulation

b. Delirium

c. Orientation

d. Perseveration

40. Which of the following will the nurse use when communicating with a
client who has a cognitive impairment?

a. Complete explanations with multiple details

b. Picture or gestures instead of words

c. Stimulating words and phrases to capture the client’s attention

d. Short words and simple sentences

41. A 75-year-old client has dementia of the Alzheimer’s type and

confabulates. The nurse understands that this client:

a. Denies confusion by being jovial.

b. Pretends to be someone else.

c. Rationalizes various behaviors.

d. Fills in memory gaps with fantasy.

42. An elderly client with Alzheimer’s disease becomes agitated and
combative when a nurse approaches to help with morning care. The most
appropriate nursing intervention in this situation would be to:

a. Tell the client family that it is time to get dressed.

b. Obtain assistance to restrain the client for safety.

c. Remain calm and talk quietly to the client.

d. Call the doctor and request an order for sedation.

43. In clients with a cognitive impairment disorder, the phenomenon of

increased confusion in the early evening hours is called:

a. Aphasia

b. Agnosia

c. Sundowning

d. Confabulation

44. Which of the following outcome criteria is appropriate for the client with
dementia?

a. The client will return to an adequate level of self-functioning.

b. The client will learn new coping mechanisms to handle anxiety.

c. The client will seek out resources in the community for support.

d. The client will follow an establishing schedule for activities of daily

living.

45. The school guidance counselor refers a family with an 8-year-old child to
the mental health clinic because of the child’s frequent fighting in school
and truancy. Which of the following data would be a priority to the nurse
doing the initial family assessment?

a. The child’s performance in school

b. Family education and work history

c. The family’s perception of the current problem

d. The teacher’s attempts to solve the problem

46. The parents of a young man with schizophrenia express feelings of
responsibility and guilt for their son’s problems. How can the nurse best
educate the family?

a. Acknowledge the parent’s responsibility.

b. Explain the biological nature of schizophrenia.

c. Refer the family to a support group

d. Teach the parents various ways they must change.

47. The nurse collecting family assessment data asks. “Who is in your family
and where do they live?” which of the following is the nurse attempting o
identify?

a. Boundaries

b. Ethnicity

c. Relationships

d. Triangles

48. According to the family systems theory, which of the following best
describes the process of differentiation?

a. Cooperative action among members of the family

b. Development of autonomy within the family

c. Incongruent massages wherein the recipient is a victim

d. Maintenance of system continuity or equilibrium

49. The nurse is interacting with a family consisting of a mother, a father, and
a hospitalized adolescent who has a diagnosis of alcohol abuse. The nurse
analyzes the situation and agrees with the adolescent’s view about family
rules. Which intervention is most appropriate?

a. The nurse should align with the adolescent, who is the family scapegoat.

b. The nurse should encourage the parents to adopt more realistic rules.

c. The nurse should encourage the adolescent to comply with parental

rules.

d. The nurse should remain objective and encourage mutual negotiation of

issues.
50. A 16-year-old girl has retuned home following hospitalization for
treatment of anorexia nervosa. The parents tell the family nurse
performing a home visit that their child has always done everything to
please them and they cannot understand her current stubbornness about
eating. The nurse analyzes the family situation and determines it is
characteristic of which relationship style?

a. Differentiation

b. Disengagement

c. Enmeshment

d. Scapegoating
Answers and Rationale Psychiatric
Nursing Practice Test I
October 28, 2009 By admin 4 Comments

View Questions

1. D. An interpreter will enable the nurse to better assess the client’s problems
and concerns. Nonverbal communication is important; however for the nurse
to fully determine the client’s problems and concerns, the assistance of an
interpreter is essential. The use of symbolic pictures and universal phrases
may assist the nurse in understanding the basic needs of the client; however
these are insufficient to assess the client with a psychiatric problem.
2. D. Psychoanalytic is based on Freud’s beliefs regarding the importance of
unconscious motivation for behavior and the role of the id and superego in
opposition to each other. Behavioral cognitive and interpersonal theories do
not emphasize unconscious conflicts as the basis for symptomatic behavior.
3. D. By acknowledging the observed behavior and asking the client to express
his feelings the nurse can best assist the client to become aware of his anxiety.
In option A, the nurse is offering an interpretation that may or may not be
accurate; the nurse is also asking a question that may be answered by a “yes”
or “no” response, which is not therapeutic. In option B, the nurse is
intervening before accurately assessing the problem. Option C, which also
encourages a “yes” or “no” response, avoids focusing on the client’s anxiety,
which is the reason for his pacing.
4. A. A client with obsessive-compulsive behavior uses this behavior to decrease
anxiety. Accepting this behavior as the client’s attempt to feel secure is
therapeutic. When a specific treatment plan is developed, other nursing
responses may also be acceptable. The remaining answer choices will increase
the client’s anxiety and therefore are inappropriate.
5. A. Education and work history would have the least significance in relation to
the client’s sexual problem. Age, health status, physical attributes and
relationship issues have great influence on sexual expression.
6. C. Inpatient treatment of a client with anorexia usually focuses initially on
establishing a plan for refeeding to combat the effects of self-induced
starvation. Refeeding is accomplished through behavioral therapy, which uses
a system of rewards and reinforcements to assist in establishing weight
restoration. Emphasizing nutrition and teaching the client about the long-term
physical consequences of anorexia maybe appropriate at a later time in the
treatment program. The nurse needs to assess the client’s mealtime behavior
continually to evaluate treatment effectiveness.
7. A. One of the core issues concerning the family of a client with anorexia is
control. The family’s acceptance of the client’s ability to make independent
decisions is key to successful family intervention. Although the remaining
options may occur during the process of therapy they would not necessarily
 indicate a successful outcome; the central family issues of dependence and
independence are not addressed in these responses.
8. D. The client with a somatoform disorder displaces anxiety onto physical
symptoms. The ability to express anxiety verbally indicates a positive change
toward improved health. The remaining responses do not indicate any positive
change toward increased coping with anxiety.
9. C. Directly questioning a client about suicide is important to determine suicide
risk. The client may not bring up this subject for several reasons, including
guilt regarding suicide, wishing not to be discovered, and his lack of trust in
staff. Behavioral cues are important, but direct questioning is essential to
determine suicide risk. Indirect questions convey to the client that the nurse is
not comfortable with the subject of suicide and, therefore, the client may be
reluctant to discuss the topic.
10. C. A client exhibiting flight of ideas typically has a continuous speech flow
and jumps from one topic to another. Speaking in coherent sentences is an
indicator that the client’s concentration has improved and his thoughts are no
longer racing. The remaining options do not relate directly to the stated
nursing diagnosis.
11. C. The nurse should take any nurse statements indicating suicidal thoughts
seriously and further assess for other risk factors. The remaining diagnoses fail
to address the seriousness of the client’s statement.
12. D. This statement provides accurate information and an element of hope for
the family of a schizophrenic client. Although the remaining statements are
true, they do not provide the empathic response the family needs after just
learning about the diagnosis. These facts can become part of the ongoing
teaching.
13. A. A client with schizophrenia, paranoid type, has distorted perceptions and
views people, institutions, and aspects of the environment as plotting against
him. The desired outcome for someone with delusional perceptions would be
to have a realistic interpretation of daily events. The client with a distorted
perception of the environment would not necessarily have impairments
affecting hygiene and grooming skills. Although taking medications and
participating in unit activities may be appropriate outcomes for nursing
intervention, these responses are not related to client perceptions.
14. D. A client with these symptoms would have poor impulse control and would
therefore be prone to acting-out behavior that may be harmful to either himself
or others. All of the remaining nursing diagnoses may apply to the client with
mania; however, the priority diagnosis would be risk for violence.
15. C. Rationalization is the defense mechanism that involves offering excuses for
maladaptive behavior. The client is defending his substance abuse by
providing reasons related to life stressors. This is a common defense
mechanism used by clients with substance abuse problems. None of the
remaining defense mechanisms involves making excuses for behaviors.
16. B. Physical aggressiveness, low stress tolerance, and a disregard for the rights
of others are common behaviors in clients with conduct disorders.
Restlessness, short attention span, and hyperactivity are typical behaviors in a
client with attention deficit hyperactivity disorder. Deterioration in social
functioning, excessive anxiety and worry and bizarre behaviors are typical in
schizophrenic disorders. Sadness, poor appetite, sleeplessness, and loss of
interest in activities are behaviors commonly seen in depressive disorders.
17. B. Babies born to heroin-dependent women are also heroin-dependent and
need to go through withdrawal. There is no evidence to support any of the
remaining answer choices.
18. D. Establishing an unbroken chain of evidence is essential in order to ensure
that the prosecution of the perpetrator can occur. The nurse will also need to
preserve the client’s privacy and identify the extent of injury. However, it is
essential that the nurse follow legal and agency guidelines for preserving
evidence. Identifying the assailant is the job of law enforcement, not the nurse.
19. D. Socioeconomic status is not a reliable predictor of abuse in the home, so it
would be the least important consideration in deciding issues of safety for the
victim of family violence. The availability of appropriate community shelters
and the ability of the nonabusing caretaker to intervene on the client’s behalf
are important factors when making safety decisions. The client’s response to
possible relocation (if the client is a competent adult) would be the most
important factor to consider; feelings of empowerment and being treated as a
competent person can help a client feel less like a victim.
20. A. In the early stage of Alzheimer’s disease, complex tasks (such as balancing
a checkbook) would be the first cognitive deficit to occur. The loss of self-care
ability, problems with relating to family members, and difficulty remembering
one’s own name are all areas of cognitive decline that occur later in the
disease process.
21. C. The client with Alzheimer’s disease can have frequent episode of labile
mood, which can best be handled by decreasing a stimulating environment and
redirecting the client’s attention. An over stimulating environment may cause
the labile mood, which will be difficult for the client to understand. The client
with Alzheimer’s disease loses the cognitive ability to respond to either humor
or logic. The client lacks any insight into his or her own behavior and
therefore will be unaware of any causative factors.
22. A. A relative deficiency of acetylcholine is associated with this disorder. The
drugs used in the early stages of Alzheimer’s disease will act to increase
available acetylcholine in the brain. The remaining neurotransmitters have not
been implicated in Alzheimer’s disease.
23. C. The most important factors to determine in this situations are the client’s
perception of the crisis event and the availability of support (including family
and friends) to provide basic needs. Although the nurse should assess the other
factors, they are not as essential as determining why the client considers this a
crisis and whether he can meet his present needs.
24. D. Crisis intervention is based on the idea that a crisis is a disturbance in
homeostasis (steady state). The goal is to help the client return to a previous
level of equilibrium in functioning. The remaining answer choices are not
considered the primary outcome of crisis intervention, although they may
occur as a side benefit.
25. B. Increased anxiety and uncertainly characterize the initiation phase in group
therapy. Group members are more self-reliant during the working and
termination phases.
26. A. As the group progresses into the working phase, group members assume
more responsibility for the group. The leader becomes more of a facilitator.
Comments about behavior in a group are indicators that the group is active and
involved. The remaining answer choices would indicate the group progress
has not advanced to the working phase.
27. C. The use of diuretics would cause sodium and water excretion, which would
increase the risk of lithium toxicity. Clients taking lithium carbonate should be
taught to increase their fluid intake and to maintain normal intake of sodium.
Concurrent use of any of the remaining medications will not increase the risk
of lithium toxicity.
28. D. In a functional family, parents typically do not agree on all issues and
problems. Open discussion of thoughts and feeling is healthy, and parental
disagreement should not cause system stress. The remaining answer choices
are life transitions that are expected to increase family stress.
29. A. Aged cheese and red wines contain the substance tyramine which, when
taken with an MAOI, can precipitate a hypertensive crisis. The other foods and
beverages do not contain significant amounts of tyramine and, therefore, are
not restricted.
30. C. Because chlorpromazine (Thorazine) can cause a significant hypotensive
effect (and possible client injury), the nurse must assess the client’s blood
pressure (lying, sitting, and standing) before administering this drug. If the
client had taken the drug previously, the nurse would also need to assess the
skin color and sclera for signs of jaundice, a possible drug side affect;
however, based on the information given here, there is no evidence that the
client has received chlorpromazine before. Although the drug can cause urine
retention, asking the client to avoid will not alter this anticholinergic effect.
31. B. The onset of action of the SSRI antidepressant paroxetine occurs around 3
to 4 weeks after drug therapy begins. Therefore, a client will seldom notice
improvement before this time. Continuing to take the drug is important for this
client.
32. B. Over-the-counter medications used for allergies and cold symptoms are
contraindicated because they will increase the sympathomimetic effects of
MAOIs, possibly causing a hypertensive crisis. None of the remaining
medications will increase the sympathomimetic response and, therefore, are
not contraindicated.
33. C. Urinary retention is a common anticholinergic side effect of psychotic
medications, and the client with benign prostatic hypertrophy would have
increased risk for this problem. Adding fiber to one’s diet and exercising
regularly are measures to counteract another anticholinergic effect,
constipation. Depending on the specific medication and how it is prescribed,
taking the medication at night may or may not be important. However, it
would have nothing to do with urinary retention in this client.
34. B. Coffee contains caffeine, which has a stimulating effect on the central
nervous system that will counteract the effect of the antianxiety medication
oxazepam. None of the remaining foods is contraindicated.
35. B. The primary purpose of Alcoholics Anonymous is to help members achieve
and maintain sobriety. Although each of the remaining answer choices may be
an outcome of attendance at Alcoholics Anonymous, the primary purpose is
directed toward sobriety of members.
36. C. A therapeutic community is designed to help individuals assume
responsibility for themselves, to learn how to respect and communicate with
others, and to interact in a positive manner. The remaining answer choices
may be outcomes of psychiatric treatment, but the use of a therapeutic
community approach is concerned with promotion of self-reliance and
cooperative adaptation to being with others.
37. ADCBE. The nurse should remain with the client to provide support and
promote safety. Reducing external stimuli, including dimming lights and
avoiding crowded areas, will help decrease anxiety. Encouraging the client to
use slow, deep breathing will help promote the body’s relaxation response,
thereby interrupting stimulation from the autonomic nervous system.
Encouraging physical activity will help him to release energy resulting from
the heightened anxiety state; this should be done only after the client has
brought his breathing under control. Teaching coping measures will help the
client learn to handle anxiety; however, this can only be accomplished when
the client’s panic has dissipated and he is better able to focus.
38. C. Set up the problem as follows: 2.5mg/10mg = Xml/2ml
X=0.5ml
39. C. The initial, most basic assessment of a client with cognitive impairment
involves determining his level of orientation (awareness of time, place, and
person). The nurse may also assess for confabulation and perseveration in a
client with cognitive impairment; but the questions in this situation would not
elicit the symptom response. Delirium is a type of cognitive impairment;
however, other symptoms are necessary to establish this diagnosis.
40. D. Short words and simple sentence minimize client confusion and enhance
communication. Complete explanations with multiple details and stimulating
words and phrases would increase confusion in a client with short attention
span and difficulty with comprehension. Although pictures and gestures may
be helpful, they would not substitute for verbal communication.
41. D. Confabulation is a communication device used by patients with dementia to
compensate for memory gaps. The remaining answer choices are incorrect.
42. C. Maintaining a calm approach when intervening with an agitated client is
extremely important. Telling the client firmly that it is time to get dressed may
increase his agitation, especially if the nurse touches him. Restraints are a last
resort to ensure client safety and are inappropriate in this situation. Sedation
should be avoided, if possible, because it will interfere with CNS functioning
and may contribute to the client’s confusion.
43. C. Sundowning is a common phenomenon that occurs after daylight hours in a
client with a cognitive impairment disorder. The other options are incorrect
responses, although all may be seen in this client.
44. D. Following established activity schedules is a realistic expectation for clients
with dementia. All of the remaining outcome statements require a higher level
of cognitive ability than can be realistically expected of clients with this
disorder.
45. C. The family’s perception of the problem is essential because change in any
one part of a family system affects all other parts and the system as a whole.
Each member of the family has been affected by the current problems related
to the school system and the nurse would be interested in the data. The child’s
performance in school and the teacher’s attempts to solve the problem are
relevant and may be assessed; however, priority would be given to the
family’s perception of the problem. The family education and work history
may be relevant, but are not a priority.
46. B. Te parents are feeling responsible and this inappropriate self-blame can be
limited by supplying them with the facts about the biologic basis of
schizophrenia. Acknowledging the patient’s responsibility is neither accurate
nor helpful to the parents and would only reinforce their feelings of guilt.
 Support groups are useful; however, the nurse needs to handle the parents’
self-blame directly instead of making a referral for this problem. Teaching the
parents various ways to change would reinforce the parental assumption of
blame; although parents can learn about schizophrenia and what is helpful and
not helpful, the approach suggested in this option implies the parents’ behavior
is at fault.
47. A. Family boundaries are parameters that define who is inside and outside the
system. The best method of obtaining this information is asking the family
directly who they consider to be members. The question asked by the nurse
would not elicit information about the family’s ethnicity or culture, nor does it
address the nature of the family relationship.
48. B. Differentiation is the process of becoming an individual developing
autonomy while staying in contact with the family system. Cooperative action
among family members does not refer to differentiation, although individuals
who have a high level of differentiation would be able to accomplish
cooperative action. Incongruent messages in which the recipient is a victim
describe double-bind communication. Maintenance of system continuity or
equilibrium is homeostasis.
49. D. The nurse who wishes to be helpful to the entire family must remain
neutral. Taking sides in a conflict situation in a family will not encourage
negotiation, which is important for problem resolution. If the nurse aligned
with the adolescent, then the nurse would be blaming the parents for the
child’s current problem; this would not help the family’s situation. Learning to
negotiate conflict is a function of a healthy family. Encouraging the parents to
adopt more realistic rules or the adolescent to comply with parental rules does
not give the family an opportunity to try to resolve problems on their own.
50. C. Enmeshment is a fusion or overinvolvement among family members
whereby the expectation exists that all members think and act alike. The child
who always acts to please her parents is an example of how enmeshment
affects development in many cases, a child who develops anorexia nervosa
exerts control only in the area of eating behavior. The remaining options are
not appropriate to the situation described.