PSYCH REVIEWER

SET A
1) The nurse is preparing a patient for the termination phase of the nurse-patient relationship.
The nurse prepares to implement which nursing task that is MOST APPROPRIATE for this
phase?
a. Planning short-term goals
b. Making appropriate referrals
c. Developing realistic solutions
d. Identifying expected outcomes

Question 1 Explanation: Tasks of the termination phase include evaluating patient performance,
evaluating achievement of expected outcomes, evaluating future needs, making appropriate
referrals and dealing with the common behaviors associated with termination. The remaining
options identify tasks appropriate for the working phase of the relationship.

2) A patient’s unresolved feelings related to loss would be MOST LIKELY observed during which
phase of the therapeutic nurse-patient relationship?
a. Trusting
b. Working
c. Orientation
d. Termination
Question 2 Explanation: In the termination phase, the relationship comes to a close. Ending
treatment sometimes may be traumatic for patients who have come to value the relationship
and the help. Because loss is an issue, any unresolved feelings related to loss may resurface
during this phase. The remaining options are not specifically associated with this issue of
unresolved feelings.

3) A client diagnosed with post-traumatic stress disorder is admitted to an inpatient psychiatric

unit for evaluation and medication stabilization. Which therapeutic communication technique
used by the nurse is an example of a broad opening?
a. “What occurred prior to the rape, and when did you go to the emergency department?”
b. “What would you like to talk about?”
c. “I notice you seem uncomfortable discussing this.”
d. “How can we help you feel safe during your stay here?”
Question 3 Explanation: The nurse’s statement, “What would you like to talk about?” is an
example of the therapeutic communication technique of giving broad openings. Using a broad
opening allows the client to take the initiative in introducing the topic and emphasizes the
importance of the client’s role in the interaction.
4) A client on an inpatient psychiatric unit tells the nurse, “I should have died because I am
totally worthless.” In order to encourage the client to continue talking about feelings, which
should be the nurse’s initial response?
a. “How would your family feel if you died?”
b. “You feel worthless now, but that can change with time.”
c. “You’ve been feeling sad and alone for some time now?”
d. “It is great that you have come in for help.”
Question 4 Explanation: This nursing statement is an example of the therapeutic communication
technique of reflection. When reflection is used, questions and feelings are referred back to the
client so that they may be recognized and accepted.

5) Which nursing statement is a good example of the therapeutic communication technique of

focusing?
a. “Describe one of the best things that happened to you this week.”
b. “I’m having a difficult time understanding what you mean.”
c. “Your counseling session is in 30 minutes. I’ll stay with you until then.”
d. “You mentioned your relationship with your father. Let’s discuss that further.”
Question 5 Explanation: This is an example of the therapeutic communication technique of
focusing. Focusing takes notice of a single idea or even a single word and works especially well
with a client who is moving rapidly from one thought to another.

6) Which nursing response is an example of the nontherapeutic communication block of

requesting an explanation?
a. “Can you tell me why you said that?”
b. “Keep your chin up. I’ll explain the procedure to you.”
c. “There is always an explanation for both good and bad behaviors.”
d. “Are you not understanding the explanation I provided?”
Question 6 Explanation: This nursing statement is an example of the nontherapeutic
communication block of requesting an explanation. Requesting an explanation is when the client
is asked to provide the reason for thoughts, feelings, behaviors, and events. Asking “why” a
client did something or feels a certain way can be very intimidating and implies that the client
must defend his or her behavior or feelings.

7) A client diagnosed with dependant personality disorder states, “Do you think I should move
from my parent’s house and get a job?” Which nursing response is most appropriate?
a. “It would be best to do that in order to increase independence.”
b. “Why would you want to leave a secure home?”
c. “Let’s discuss and explore all of your options.”
d. “I’m afraid you would feel very guilty leaving your parents.”
 Question 7 Explanation: The most appropriate response by the nurse is, “Let’s discuss and
explore all of your options.” In this example, the nurse is encouraging the client to formulate
ideas and decide independently the appropriate course of action.

8) Which example of a therapeutic communication technique would be effective in the planning

phase of the nursing process?
a. “We’ve discussed past coping skills. Let’s see if these coping skills can be effective now.”
b. “Please tell me in your own words what brought you to the hospital.”
c. “This new approach worked for you. Keep it up.”
d. “I notice that you seem to be responding to voices that I do not hear.”
Question 8 Explanation: This is an example of the therapeutic communication technique of
formulating a plan of action. By the use of this technique, the nurse can help the client plan in
advance to deal with a stressful situation which may prevent anger and/or anxiety from
escalating to an unmanageable level.

9) Which statement demonstrates the BEST understanding of the nurse’s role regarding ensuring
that each client’s rights are respected?
a. “Autonomy is the fundamental right of each and every client.”
b. “A patient’s rights are guaranteed by both state and federal laws.”
c. “Being respectful and concerned will ensure that I’m attentive to my patient’s rights.”
d. “Regardless of the patient’s conditions, all nurses have the duty to respect patient
rights.”
Question 9 Explanation: The nurse needs to respect and have concern for the patient; this is
vital to protecting the patient’s rights. While it is true the autonomy is a basic client right, there
are other rights that must also be both respected and facilitated. State and federal laws do
protect a patient’s rights, but it is sensitivity to those rights that will ensure that the nurse
secures these rights for the patient. It is a fact that safeguarding a patient’s rights are a nursing
responsibility, but stating that fact does not show understanding or respect for the concept.

10) When interviewing a client, which nonverbal behavior should a nurse employ?
a. Maintaining indirect eye contact with the client
b. Providing space by leaning back away from the client
c. Sitting squarely, facing the client
d. Maintaining open posture with arms and legs crossed
Question 10 Explanation: When interviewing a client, the nurse should employ the nonverbal
behavior of sitting squarely, facing the client. Facilitative skills for active listening can be
identified by the acronym SOLER. SOLER includes sitting squarely facing the client (S), open
posture when interacting with a client (O), leaning forward toward the client (L), establishing
eye contact (E), and relaxing (R).
11) A mother rescues two of her four children from a house fire. In the emergency department,
she cries, “I should have gone back in to get them. I should have died, not them.” What is the
nurse’s best response?
a. “The smoke was too thick. You couldn’t have gone back in.”
b. “You’re feeling guilty because you weren’t able to save your children.”
c. “Focus on the fact that you could have lost all four of your children.”
d. “It’s best if you try not to think about what happened. Try to move on.”
Question 11 Explanation: The best response by the nurse is, “You’re experiencing feelings of
guilt because you weren’t able to save your children.” This response utilizes the therapeutic
communication technique of reflection which identifies a client’s emotional response and
reflects these feelings back to the client so that they may be recognized and accepted.

12) A patient diagnosed with terminal cancer says to the nurse “I’m going to die, and I wish my
family would stop hoping for a cure! I get so angry when they carry on like this. After all, I’m
the one who’s dying.” Which response by the nurse is therapeutic?
a. “Have you shared your feelings with your family?”
b. “I think we should talk more about your anger with your family.”
c. “You’re feeling angry that your family continues to hope for you to be cured?”
d. “You are probably very depressed, which is understandable with such a diagnosis.”
Question 12 Explanation: Restating is a therapeutic communication technique in which the
nurse repeats what the patient says to show understanding and to review what was said. While
it is appropriate for the nurse to attempt to assess the patient’s ability to discuss feelings openly
with family members, it does not help the patient discuss the feelings causing the anger. The
nurse’s attempt to focus on the central issue of anger is premature. The nurse would never
make a judgment regarding the reason for the patient’s feeling, this is non-therapeutic in the
one-to-one relationship.

13) A patient admitted to a mental health unit for treatment of psychotic behavior spends hours
at the locked exit door shouting. “Let me out. There’s nothing wrong with me. I don’t belong
here.” What defense mechanism is the patient implementing?
a. Denial
b. Projection
c. Regression
d. Rationalization
Question 13 Explanation: Denial is refusal to admit to a painful reality, which is treated as if it
does not exist. In projection, a person unconsciously rejects emotionally unacceptable features
and attributes them to other persons, objects, or situations. Regression allows the patient to
return to an earlier, more comforting, although less mature, way of behaving. Rationalization is
justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable
explanations that satisfy the teller and the listener.
14) Which therapeutic communication technique should the nurse use when communicating with
a client who is experiencing auditory hallucinations?
a. “My sister has the same diagnosis as you and she also hears voices.”
b. “I understand that the voices seem real to you, but I do not hear any voices.”
c. “Why not turn up the radio so that the voices are muted.”
d. “I wouldn’t worry about these voices. The medication will make them disappear.”
Question 14 Explanation: This is an example of the therapeutic communication technique of
presenting reality. Presenting reality is when the client has a misperception of the environment.
The nurse defines reality or indicates his or her perception of the situation for the client.

15) A client’s younger daughter is ignoring curfew. The client states, “I’m afraid she will get
pregnant.” The nurse responds, “Hang in there. Don’t you think she has a lot to learn about
life?” This is an example of which communication block?
a. Requesting an explanation
b. Belittling the client
c. Making stereotyped comments
d. Probing
Question 15 Explanation: This is an example of the nontherapeutic communication block of
making stereotyped comments. Clichés and trite expressions are meaningless in a therapeutic
nurse-client relationship.

16) A client states, “You won’t believe what my husband said to me during visiting hours. He has
no right treating me that way.” Which nursing response would best assess the situation that
occurred?
a. “Does your husband treat you like this very often?”
b. “What do you think is your role in this relationship?”
c. “Why do you think he behaved like that?”
d. “Describe what happened during your time with your husband.”
Question 16 Explanation: This is an example of the therapeutic communication technique of
exploring. The purpose of using exploring is to delve further into the subject, idea, experience,
or relationship. This technique is especially helpful with clients who tend to remain on a
superficial level of communication.

17) A patient admitted voluntarily for treatment of an anxiety disorder demands to be released
from the hospital. Which action should the nurse take INITIALLY?
a. Contact the patient’s health care provider (HCP).
b. Call the patient’s family to arrange for transportations.
c. Attempt to persuade the patient to stay for only a few more days.
d. Tell the patient that leaving would likely result in an involuntary commitment.
Question 17 Explanation: In general, patients seek, voluntary admission. Voluntary patients have
the right to demand and obtain release. The nurse needs to be familiar with the state and
 facility policies and procedures. The best nursing action is to contact the HCP, who has the
authority to discuss discharge with the patient. While arranging for safe transportation is
appropriate it is premature in this situation and should be done only with the patient’s’
permission. While it is appropriate to discuss why the patient feels the need to leave and the
possible outcomes of leaving against medical advice, attempting to get the patient to agree to
staying “a few more days” has little value and will not likely be successful. Many states require
that the patient submit a written release notice to the facility staff members, who reevaluate
the patient’s condition for possible conversion to involuntary status if necessary, according to
criteria established by law. While this is a possibility, it should not be used as a threat to the
patient.

18) After fasting from 10 p.m. the previous evening, a client finds out that the blood test has been
canceled. The client swears at the nurse and states, “You are incompetent!” Which is the
nurse’s best response?
a. “Do you believe that I was the cause of your blood test being canceled?”
b. “I see that you are upset, but I feel uncomfortable when you swear at me.”
c. “Have you ever thought about ways to express anger appropriately?”
d. “I’ll give you some space. Let me know if you need anything.”
Question 18 Explanation: This is an example of the appropriate use of feedback. Feedback
should be directed toward behavior that the client has the capacity to modify.

19) A student nurse is learning about the appropriate use of touch when communicating with
clients diagnosed with psychiatric disorders. Which statement by the instructor best provides
information about this aspect of therapeutic communication?
a. “Touch carries a different meaning for different individuals.”
b. “Touch is often used when deescalating volatile client situations.”
c. “Touch is used to convey interest and warmth.”
d. “Touch is best combined with empathy when dealing with anxious clients.”
Question 19 Explanation: Touch can elicit both negative and positive reactions, depending on
the people involved and the circumstances of the interaction.

20) A patient being seen in the emergency department immediately after being sexually assaulted
appears calm and controlled. The nurse analyzes this behavior as indicating which defense
mechanism?
a. Denial
b. Projection
c. Rationalization
d. Intellectualization
Question 20 Explanation: Denial is refusal to admit to a painful reality and may be a response by
a victim of sexual abuse. In this case the patient is not acknowledging the trauma of the assault
either verbally or nonverbally. Projection is transferring one’s internal feelings, thoughts, and
unacceptable ideas and traits to someone else. Rationalization is justifying the unacceptable
 attributes about oneself. Intellectualization is the excessive use of abstract thinking or
generalizations to decrease painful thinking.

21) When reviewing the admission assessment, the nurse notes that a patient was admitted to
the mental health unity involuntarily. Based on this type of admission, the nurse should
provide which intervention for this patient?
a. Monitor closely for harm to self or others.
b. Assist in completing an application for admission.
c. Supply the patient with written information about their mental illness.
d. Provide an opportunity for the family to discuss why they felt the admission was
needed.
Question 21 Explanation: Involuntary admission is necessary when a person is a danger to self or
others or is in need of psychiatric treatment regardless of the patient’s willingness to consent to
the hospitalization. A written request is a component of a voluntary admission. Providing written
information regarding the illness is likely premature initially. The family may have had no role to
play in the patient’s’ admission.

22) On review of the patients record, the nurse notes the admission was voluntary. Based on this
information, the nurse anticipates which patient behavior?
a. Fearfulness regarding treatment measures.
b. Anger and aggressiveness directed toward others.
c. An understanding of the pathology and symptoms of the diagnosis.
d. A willingness to participate in the planning of the care and treatment plan.
Question 22 Explanation: In general, patients seek voluntary admission. If a patient seeks
voluntary admission, the most likely expectations is the patient will participate in the treatment
program since they are actively seeking help. The remaining options are not characteristics of
this type of admission. Fearfulness, anger, and aggressiveness are more characteristic of an
involuntary admission. Voluntary admission does not guarantee a patient’s understanding of
their illness, only of their desire for help.

23) During a nurse-client interaction, which nursing statement may belittle the client’s feelings
and concerns?
a. “Don’t worry. Everything will be alright.”
b. “You appear uptight.”
c. “I notice you have bitten your nails to the quick.”
d. “You are jumping to conclusions.”
Question 23 Explanation: This nursing statement is an example of the nontherapeutic
communication block of belittling feelings. Belittling feelings occur when the nurse misjudges
the degree of the client’s discomfort, thus a lack of empathy and understanding may be
conveyed.
24) A nurse maintains an uncrossed arm and leg posture. This nonverbal behavior is reflective of
which letter of the SOLER acronym for active listening?
a. S
b. O
c. L
d. E
e. R
Question 24 Explanation: The nurse should identify that maintaining an uncrossed arm and leg
posture is nonverbal behavior that reflects the “O” in the active-listening acronym SOLER. The
acronym SOLER includes sitting squarely facing the client (S), open posture when interacting
with the client (O), leaning forward toward the client (L), establishing eye contact (E), and
relaxing (R).

25) Which therapeutic communication technique is being used in this nurse-client interaction?
Client: “My father spanked me often.”
Nurse: “Your father was a harsh disciplinarian.”
a. Restatement
b. Offering general leads
c. Focusing
d. Accepting
Question 25 Explanation: The nurse is using the therapeutic communication technique of
restatement. Restatement involves repeating the main idea of what the client has said. The
nurse uses this technique to communicate that the client’s statement has been heard and
understood.

26) A mother rescues two of her four children from a house fire. In the emergency department,
she cries, “I should have gone back in to get them. I should have died, not them.” What is the
nurse’s best response?
a. “The smoke was too thick. You couldn’t have gone back in.”
b. “You’re feeling guilty because you weren’t able to save your children.”
c. “Focus on the fact that you could have lost all four of your children.”
d. “It’s best if you try not to think about what happened. Try to move on.”
Question 26 Explanation: The best response by the nurse is, “You’re experiencing feelings of
guilt because you weren’t able to save your children.” This response utilizes the therapeutic
communication technique of reflection which identifies a client’s emotional response and
reflects these feelings back to the client so that they may be recognized and accepted.
27) After assertiveness training, a formerly passive client appropriately confronts a peer in group
therapy. The group leader states, “I’m so proud of you for being assertive. You are so good!”
Which communication technique has the leader employed?
a. The nontherapeutic technique of giving approval
b. The nontherapeutic technique of interpreting
c. The therapeutic technique of presenting reality
d. The therapeutic technique of making observations
Question 27 Explanation: The group leader has employed the nontherapeutic technique of
giving approval. Giving approval implies that the nurse has the right to pass judgment on
whether the client’s ideas or behaviors are “good” or “bad.” This creates a conditional
acceptance of the client.

28) Which nursing statement is a good example of the therapeutic communication technique of
offering self?
a. “I think it would be great if you talked about that problem during our next group
session.”
b. “Would you like me to accompany you to your electroconvulsive therapy treatment?”
c. “I notice that you are offering help to other peers in the milieu.”
d. “After discharge, would you like to meet me for lunch to review your outpatient
progress?”
Question 28 Explanation: This is an example of the therapeutic communication technique of
offering self. Offering self makes the nurse available on an unconditional basis, increasing
client’s feelings of self-worth. Professional boundaries must be maintained when using the
technique of offering self.

29) A client is struggling to explore and solve a problem. Which nursing statement would verbalize
the implication of the client’s actions?
a. “You seem to be motivated to change your behavior.”
b. “How will these changes affect your family relationships?”
c. “Why don’t you make a list of the behaviors you need to change.”
d. “The team recommends that you make only one behavioral change at a time.”
Question 29 Explanation: This is an example of the therapeutic communication technique of
verbalizing the implied. Verbalizing the implied puts into words what the client has only implied
or said indirectly.

30) Which therapeutic communication technique is being used in this nurse-client interaction?
Client: “When I get angry, I get into a fistfight with my wife or I take it out on the kids.”
Nurse: “I notice that you are smiling as you talk about this physical violence.”
a. Encouraging comparison
b. Exploring
c. Formulating a plan of action
 d. Making observations
Question 30 Explanation: The nurse is using the therapeutic communication technique of
making observations when noting that the client smiles when talking about physical violence.
The technique of making observations encourages the client to compare personal perceptions
with those of the nurse.

31) Which therapeutic communication technique is being used in this nurse-client interaction?
Client: “When I am anxious, the only thing that calms me down is alcohol.”
Nurse: “Other than drinking, what alternatives have you explored to decrease anxiety?”
a. Reflecting
b. Making observations
c. Formulating a plan of action
d. Giving recognition
Question 31 Explanation: The nurse is using the therapeutic communication technique of
formulating a plan of action to help the client explore alternatives to drinking alcohol. The use of
this technique, rather than direct confrontation regarding the client’s poor coping choice, may
serve to prevent anger or anxiety from escalating.

32) What is the purpose of a nurse providing appropriate feedback?

a. To give the client good advice
b. To advise the client on appropriate behaviors
c. To evaluate the client’s behavior
d. To give the client critical information
Question 32 Explanation: The purpose of providing appropriate feedback is to give the client
critical information. Feedback should not be used to give advice or evaluate behaviors.

33) A client slammed a door on the unit several times. The nurse responds, “You seem angry.” The
client states, “I’m not angry.” What therapeutic communication technique has the nurse
employed and what defense mechanism is the client unconsciously demonstrating?
a. Making observations and the defense mechanism of suppression
b. Verbalizing the implied and the defense mechanism of denial
c. Reflection and the defense mechanism of projection
d. Encouraging descriptions of perceptions and the defense mechanism of displacement
Question 33 Explanation: This is an example of the therapeutic communication technique of
verbalizing the implied. The nurse is putting into words what the client has only implied by
words or actions. Denial is the refusal of the client to acknowledge the existence of a real
situation, the feelings associated with it, or both.
34) A patient experiencing disturbed thought processes believes that his food is being poisoned.
Which communication technique should the use to encourage the patient to eat?
a. Using open-ended questions and silence
b. Sharing personal preference regarding food choices
c. Documenting reasons why the patient does not want to eat
d. Offering opinions about the necessity of adequate nutrition
Question 34 Explanation: Open-ended questions and silence are strategies use to encourage
patients to discuss their problems. Sharing personal food preferences is not a patient-centered
intervention. The remaining options are not helpful to the patient because they do not
encourage the patient to express feelings. The nurse should not offer opinions and should
encourage the patient to identify the reasons for the behavior.

35) Which nursing statement is a good example of the therapeutic communication technique of
giving recognition?
a. “You did not attend group today. Can we talk about that?”
b. “I’ll sit with you until it is time for your family session.”
c. “I notice you are wearing a new dress and you have washed your hair.”
d. “I’m happy that you are now taking your medications. They will really help.”
Question 35 Explanation: This is an example of the therapeutic communication technique of
giving recognition. Giving recognition acknowledges and indicates awareness. This technique is
more appropriate than complimenting the client which reflects the nurse’s judgment.

36) The nurse asks a newly admitted client, “What can we do to help you?” What is the purpose of
this therapeutic communication technique?
a. To reframe the client’s thoughts about mental health treatment
b. To put the client at ease
c. To explore a subject, idea, experience, or relationship
d. To communicate that the nurse is listening to the conversation
Question 36 Explanation: This is an example of the therapeutic communication technique of
exploring. The purpose of using exploring is to delve further into the subject, idea, experience,
or relationship. This technique is especially helpful with clients who tend to remain on a
superficial level of communication.

37) A nurse is assessing a client diagnosed with schizophrenia for the presence of hallucinations.
Which therapeutic communication technique used by the nurse is an example of making
observations?
a. “You appear to be talking to someone I do not see.”
b. “Please describe what you are seeing.”
c. “Why do you continually look in the corner of this room?”
d. “If you hum a tune, the voices may not be so distracting.”
 Question 37 Explanation: The nurse is making an observation when stating, “You appear to be
talking to someone I do not see.” Making observations involves verbalizing what is observed or
perceived. This encourages the client to recognize specific behaviors and make comparisons
with the nurse’s perceptions.

38) When the community health nurse visits a patient at home, the patient states, “I haven’t slept
the last couple of nights.” Which response by the nurse illustrates a therapeutic
communication response to this patient.
a. “I see.”
b. “Really?”
c. “You’re having difficulty sleeping?”
d. “Sometimes, I have trouble sleeping too.”
Question 38 Explanation: The correct option uses the therapeutic communication technique of
restatement. Although restatement is a technique that has a prompting component to it, it
repeats the patients major theme, which assists the nurse to obtain a more specific perception
of the problem from the patient. The remaining options are not therapeutic responses since
none encourage the patient to expand on the problem. Offering personal experiences moves
the focus away from the patient and onto the nurse

39) Nurse Patrick is interviewing a newly admitted psychiatric client. Which nursing statement is
an example of offering a “general lead”?
a. “Do you know why you are here?”
b. “Are you feeling depressed or anxious?”
c. “Yes, I see. Go on.”
d. “Can you chronologically order the events that led to your admission?”
Question 39 Explanation: The nurse’s statement, “Yes, I see. Go on.” is an example of the
therapeutic communication technique of a general lead. Offering a general lead encourages the
client to continue sharing information.

40) The nurse calls security and has physical restraints applied when a client who was admitted
voluntarily becomes both physically and verbally abusive while demanding to be discharged
from the hospital. Which represents the possible legal ramifications for the nurse associated
with these interventions? Select all that apply.
a. Libel
b. Battery
c. Assault
d. Slander
e. False Imprisonment
Question 40 Explanation: False imprisonment is an act with the intent to confine a person to a
specific area. The nurse can be charged with false imprisonment if the nurse prohibits a patient
from leaving the hospital if the patient has been admitted voluntarily and if no agency or legal
 policies exist for detaining the patient. Assault and battery are related to the act of restraining
the patient in a situation that did not meet criteria for such an intervention. Libel and slander
are not applicable here since the nurse did not write or verbally make untrue statements about
the patient.

41) A client who frequently exhibits angry outbursts is diagnosed with antisocial personality
disorder. Which appropriate feedback should a nurse provide when this client experiences an
angry outburst?
a. “Why do you continue to alienate your peers by your angry outbursts?”
b. “You accomplish nothing when you lose your temper like that.”
c. “Showing your anger in that manner is very childish and insensitive.”
d. “During group, you raised your voice, yelled at a peer, left, and slammed the door.”
Question 41 Explanation: The nurse is providing appropriate feedback when stating, “During
group, you raised your voice, yelled at a peer, left, and slammed the door.” Giving appropriate
feedback involves helping the client consider a modification of behavior. Feedback should give
information to the client about how he or she is perceived by others. Feedback should not be
evaluative in nature or be used to give advice.

42) Which of the following individuals are communicating a message? (Select all that apply.)
a. A mother spanking her son for playing with matches
b. A teenage boy isolating himself and playing loud music
c. A biker sporting an eagle tattoo on his biceps
d. A teenage girl writing, “No one understands me”
e. A father checking for new e-mail on a regular basis
Question 42 Explanation: The nurse should determine that spanking, isolating, getting tattoos,
and writing are all ways in which people communicate messages to others. It is estimated that
about 70% to 90% of communication is nonverbal.

43) A nurse states to a client, “Things will look better tomorrow after a good night’s sleep.” This is
an example of which communication technique?
a. The therapeutic technique of “giving advice”
b. The therapeutic technique of “defending”
c. The nontherapeutic technique of “presenting reality”
d. The nontherapeutic technique of “giving false reassurance”
Question 43 Explanation: The nurse’s statement, “Things will look better tomorrow after a good
night’s sleep.” is an example of the nontherapeutic technique of giving false reassurance. Giving
false reassurance indicates to the client that there is no cause for anxiety, thereby devaluing the
client’s feelings.
44) A student nurse tells the instructor, “I’m concerned that when a client asks me for advice I
won’t have a good solution.” Which should be the nursing instructor’s best response?
a. “It’s scary to feel put on the spot by a client. Nurses don’t always have the answer.”
b. “Remember, clients, not nurses, are responsible for their own choices and decisions.”
c. “Just keep the client’s best interests in mind and do the best that you can.”
d. “Set a goal to continue to work on this aspect of your practice.”
Question 44 Explanation: Giving advice tells the client what to do or how to behave. It implies
that the nurse knows what is best and that the client is incapable of any self-direction. It
discourages independent thinking.

45) A newly admitted client diagnosed with obsessive-compulsive disorder (OCD) washes hands
continually. This behavior prevents unit activity attendance. Which nursing statement best
addresses this situation?
a. “Everyone diagnosed with OCD needs to control their ritualistic behaviors.”
b. “It is important for you to discontinue these ritualistic behaviors.”
c. “Why are you asking for help if you won’t participate in unit therapy?”
d. “Let’s figure out a way for you to attend unit activities and still wash your hands.”
Question 45 Explanation: The most appropriate statement by the nurse is, “Let’s figure out a
way for you to attend unit activities and still wash your hands.” This statement reflects the
therapeutic communication technique of formulating a plan of action. The nurse attempts to
work with the client to develop a plan without damaging the therapeutic relationship or
increasing the client’s anxiety.

46) The nurse in the mental health unit recognizes which of the following as therapeutic
communication techniques? Select all that apply.
a. Restating
b. Listening
c. Asking the patient “Why?”
d. Maintaining neutral responses
e. Providing acknowledgment and feedback
f. Giving advice and approval or disapproval
Question 46 Explanation: Therapeutic communication techniques include listening, maintaining
silence, maintaining neutral responses, using broad openings and open-ended questions,
focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting,
providing acknowledgment and feedback, giving information, presenting reality, encouraging
formulation of a plan of action, providing nonverbal encouragement, and summarizing Asking
why is often interpreted as being accusatory by the patient and should also be avoided.
Providing advice or giving approval or disapproval are barriers to communication.

47) A client tells the nurse, “I feel bad because my mother does not want me to return home after
I leave the hospital.” Which nursing response is therapeutic?
 a. “It’s quite common for clients to feel that way after a lengthy hospitalization.”
b. “Why don’t you talk to your mother? You may find out she doesn’t feel that way.”
c. “Your mother seems like an understanding person. I’ll help you approach her.”
d. “You feel that your mother does not want you to come back home?”
Question 47 Explanation: This is an example of the therapeutic communication technique of
restatement. Restatement is the repeating of the main idea that the client has verbalized. This
lets the client know whether or not an expressed statement has been understood and gives him
or her the chance to continue, or clarify if necessary.

48) An instructor is correcting a nursing student’s clinical worksheet. Which instructor statement
is the best example of effective feedback?
a. “Why did you use the client’s name on your clinical worksheet?”
b. “You were very careless to refer to your client by name on your clinical worksheet.”
c. “Surely you didn’t do this deliberately, but you breached confidentiality by using the
client’s name.”
d. “It is disappointing that after being told, you’re still using client names on your
worksheet.”
Question 48 Explanation: The instructor’s statement, “Surely you didn’t do this deliberately, but
you breached confidentiality by using the client’s name.” is an example of effective feedback.
Feedback is a method of communication to help others consider a modification of behavior.
Feedback should be descriptive, specific, and directed toward a behavior that the person has the
capacity to modify and should impart information rather than offer advice or criticize the
individual.

49) The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store.
The neighbors says to the nurse, “How is Mary doing? She is my best friend and is seen at your
clinic every week.” Which is the MOST APPROPRIATE nursing response?
a. “I cannot discuss any patient situation with you.”
b. “If you want to know about Mary, you need t ask her yourself.”
c. “Only because you’re worried about a friend, I’ll tell you that she is improving.”
d. “Being her friend, you know she is having a difficult time and deserves her privacy.”
Question 49 Explanation: The nurse is required to maintain confidentiality regarding the patient
and the patient’s care. Confidentiality is basic to the therapeutic relationship and is a patient’s
right. The most appropriate response to the neighbor is the statement of that responsibility in a
direct, but polite manner. A blunt statement that does not acknowledge why the nurse cannot
reveal patient information may be taken as disrespectful and uncaring. The remaining options
identify statements that do not maintain patient confidentiality.
 50) A patient with a diagnosis of major depression who has attempted suicide says to the nurse, “I
should have died! I’ve always been a failure. Nothing ever goes right for me.” Which response
demonstrates therapeutic communication?
a. “You have everything to live for.”
b. “Why do you see yourself as a failure?”
c. “Feeling like this is all part of being depressed.”
d. “You’ve been feeling like a failure for a while?”
Question 50 Explanation: Responding to the feelings expressed by a patient is an effective
therapeutic communication technique. The correct option is an example of the use of restating.
The remaining options block communication because they minimize the patient’s experience
and do not facilitate exploration of the patient’s expressed feelings. In addition, use of the word
“why” is nontherapeutic.

SET B
1) Which of the following foods would the nurse Trish eliminate from the diet of a client in
alcohol withdrawal?
a. Orange Juice
b. Regular Coffee
c. Milk
d. Tea
Question 1 Explanation: Regular coffee contains caffeine which acts as psychomotor stimulants
and leads to feelings of anxiety and agitation. Serving coffee top the client may add to tremors
or wakefulness.

2) A female client is admitted with a diagnosis of delusions of GRANDEUR. This diagnosis reflects
a belief that one is:
a. Being Killed
b. Responsible for evil world
c. Connected to client unrelated to oneself
d. Highly famous and important
Question 2 Explanation: Delusion of grandeur is a false belief that one is highly famous and
important.

3) Nurse Tina is caring for a client with depression who has not responded to antidepressant
medication. The nurse anticipates that what treatment procedure may be prescribed?
a. Neuroleptic medication
b. Short term seclusion
c. Electroconvulsive therapy
d. Psychosurgery
Question 3 Explanation: Electroconvulsive therapy is an effective treatment for depression that
has not responded to medication.
4) Nurse Joey is aware that the signs & symptoms that would be most specific for diagnosis
anorexia are?
a. Compulsive behavior, excessive fears & nausea
b. Excessive weight loss, amenorrhea & abdominal distension
c. Slow pulse, 10% weight loss & alopecia
d. Excessive activity, memory lapses & an increased pulse
Question 4 Explanation: These are the major signs of anorexia nervosa. Weight loss is excessive
(15% of expected weight).

5) Nurse Hazel is caring for a male client who experience false sensory perceptions with no basis
in reality. This perception is known as:
a. Neologisms
b. Hallucinations
c. Loose associations
d. Delusions
Question 5 Explanation: Hallucinations are visual, auditory, gustatory, tactile or olfactory
perceptions that have no basis in reality.

6) Marco approached Nurse Trish asking for advice on how to deal with his alcohol addiction.
Nurse Trish should tell the client that the only effective treatment for alcoholism is:
a. Aversion Therapy
b. Psychotherapy
c. Total abstinence
d. Alcoholics anonymous (A.A.)
Question 6 Explanation: Total abstinence is the only effective treatment for alcoholism.

7) A 20 year old client was diagnosed with dependent personality disorder. Which behavior is
most likely to be evidence of ineffective individual coping?
a. Showing interest in solitary activities
b. Recurrent self-destructive behavior
c. Avoiding relationship
d. Inability to make choices and decision without advise
Question 7 Explanation: Individual with dependent personality disorder typically shows
indecisiveness submissiveness and clinging behavior so that others will make decisions with
them.

8) Nurse Jonel is providing information to a community group about violence in the family.
Which statement by a group member would indicate a need to provide additional
information?
a. “Abuse occurs more in low-income families”
b. “Abuser usually have poor self-esteem”
c. “Abuser are often jealous or self-centered”
d. “Abuser use fear and intimidation”
 Question 8 Explanation: Personal characteristics of abuser include low self-esteem, immaturity,
dependence, insecurity and jealousy.

9) A long term goal for a paranoid male client who has unjustifiably accused his wife of having
many extramarital affairs would be to help the client develop:
a. Better self control
b. Feeling of self worth
c. Insight into his behavior
d. Faith in his wife
Question 9 Explanation: Helping the client to develop feeling of self worth would reduce the
client’s need to use pathologic defenses.

10) Mario is complaining to other clients about not being allowed by staff to keep food in his
room. Which of the following interventions would be most appropriate?
a. Ignoring the clients behavior
b. Setting limits on the behavior
c. Reprimanding the client
d. Allowing a snack to be kept in his room
Question 10 Explanation: The nurse needs to set limits in the client’s manipulative behavior to
help the client control dysfunctional behavior. A consistent approach by the staff is necessary to
decrease manipulation.

11) Nurse Anna can minimize agitation in a disturbed client by?

a. ensuring constant client and staff contact
b. increasing appropriate sensory perception
c. Increasing stimulation
d. limiting unnecessary interaction
Question 11 Explanation: Limiting unnecessary interaction will decrease stimulation and
agitation.

12) Which of the following would Nurse Hazel expect to assess for a client who is exhibiting late
signs of heroin withdrawal?
a. Restlessness & Irritability
b. Yawning & diaphoresis
c. Vomiting and Diarrhea
d. Constipation & steatorrhea
Question 12 Explanation: Vomiting and diarrhea are usually the late signs of heroin withdrawal,
along with muscle spasm, fever, nausea, repetitive, abdominal cramps and backache.

13) Nurse Monet is caring for a female client who has suicidal tendency. When accompanying the
client to the restroom, Nurse Monet should…
a. Observe her
b. Give her privacy
c. Allow her to urinate
 d. Open the window and allow her to get some fresh air
Question 13 Explanation: The Nurse has a responsibility to observe continuously the acutely
suicidal client. The Nurse should watch for clues, such as communicating suicidal thoughts, and
messages; hoarding medications and talking about death.

14) During electroconvulsive therapy (ECT) the client receives oxygen by mask via positive
pressure ventilation. The nurse assisting with this procedure knows that positive pressure
ventilation is necessary because?
a. Grand mal seizure activity depresses respirations
b. Decrease oxygen to the brain increases confusion and disorientation
c. Muscle relaxations given to prevent injury during seizure activity depress respirations.
d. Anesthesia is administered during the procedure
Question 14 Explanation: A short acting skeletal muscle relaxant such as succinylcholine
(Anectine) is administered during this procedure to prevent injuries during seizure.

15) Linda is pacing the floor and appears extremely anxious. The duty nurse approaches in an
attempt to alleviate Linda’s anxiety. The most therapeutic question by the nurse would be?
a. Would you like me to talk with you?
b. Ignore the client
c. Would you like to watch TV?
d. Are you feeling upset now?
Question 15 Explanation: The nurse presence may provide the client with support & feeling of
control.

16) Nurse Penny is aware that the symptoms that distinguish post traumatic stress disorder from
other anxiety disorder would be:
a. Lack of interest in family & others
b. Depression and a blunted affect when discussing the traumatic situation
c. Avoidance of situation & certain activities that resemble the stress
d. Re-experiencing the trauma in dreams or flashback
Question 16 Explanation: Experiencing the actual trauma in dreams or flashback is the major
symptom that distinguishes post traumatic stress disorder from other anxiety disorder.

17) When planning care for a female client using ritualistic behavior, Nurse Gina must recognize
that the ritual:
a. Helps the client focus on the inability to deal with reality
b. Helps the client control the anxiety
c. Is under the client’s conscious control
d. Is used by the client primarily for secondary gains
Question 17 Explanation: The rituals used by a client with obsessive compulsive disorder help
control the anxiety level by maintaining a set pattern of action.

18) A nursing care plan for a male client with bipolar I disorder should include:
a. Designing activities that will require the client to maintain contact with reality
 b. Providing a structured environment
c. Touching the client provide assurance
d. Engaging the client in conversing about current affairs
Question 18 Explanation: Structure tends to decrease agitation and anxiety and to increase the
client’s feeling of security.

19) A 60 year old female client who lives alone tells the nurse at the community health center “I
really don’t need anyone to talk to”. The TV is my best friend. The nurse recognizes that the
client is using the defense mechanism known as?
a. Denial
b. Projection
c. Displacement
d. Sublimation
Question 19 Explanation: The client statement is an example of the use of denial, a defense that
blocks problem by unconscious refusing to admit they exist.

20) Nurse Perry is aware that language development in autistic child resembles:
a. Shuttering
b. Scanning speech
c. Speech lag
d. Echolalia
Question 20 Explanation: The autistic child repeat sounds or words spoken by others.

21) A client is experiencing anxiety attack. The most appropriate nursing intervention should
include?
a. Ask the client to play with other clients
b. Turning on the television
c. Leaving the client alone
d. Staying with the client and speaking in short sentences
Question 21 Explanation: Appropriate nursing interventions for an anxiety attack include using
short sentences, staying with the client, decreasing stimuli, remaining calm and medicating as
needed.

22) To further assess a client’s suicidal potential. Nurse Katrina should be especially alert to the
client expression of:
a. Frustration & fear of death
b. Anxiety & loneliness
c. Helplessness & hopelessness
d. Anger & resentment
Question 22 Explanation: The expression of these feeling may indicate that this client is unable
to continue the struggle of life.

23) A neuromuscular blocking agent is administered to a client before ECT therapy. The Nurse
should carefully observe the client for?
 a. Respiratory difficulties
b. Dizziness
c. Nausea and vomiting
d. Seizures
Question 23 Explanation: Neuromuscular Blocker, such as SUCCINYLCHOLINE (Anectine)
produces respiratory depression because it inhibits contractions of respiratory muscles.

24) A male client who is experiencing disordered thinking about food being poisoned is admitted
to the mental health unit. The nurse uses which communication technique to encourage the
client to eat dinner?
a. Verbalizing reasons that the client may not choose to eat
b. Using open ended question and silence
c. Offering opinion about the need to eat
d. Focusing on self-disclosure of own food preference
Question 24 Explanation: Open ended questions and silence are strategies used to encourage
clients to discuss their problem in descriptive manner.

25) A male client is diagnosed with schizotypal personality disorder. Which signs would this client
exhibit during social situation?
a. Emotional affect
b. Aggressive behavior
c. Independence need
d. Paranoid thoughts
Question 25 Explanation: Clients with schizotypal personality disorder experience excessive
social anxiety that can lead to paranoid thoughts.

26) When teaching parents about childhood depression Nurse Trina should say?
a. Is short in duration & resolves easily
b. It may appear acting out behavior
c. Does not respond to conventional treatment
d. Looks almost identical to adult depression
Question 26 Explanation: Children have difficulty verbally expressing their feelings, acting out
behavior, such as temper tantrums, may indicate underlying depression.

27) Nurse Monette recognizes that the focus of environmental (MILIEU) therapy is to:
a. Manipulate the environment to bring about positive changes in behavior
b. Use natural remedies rather than drugs to control behavior
c. Allow the client’s freedom to determine whether or not they will be involved in
activities
d. Role play life events to meet individual needs
Question 27 Explanation: Environmental (MILIEU) therapy aims at having everything in the
client’s surrounding area toward helping the client.
28) Nurse Tina is caring for a client with delirium and states that “look at the spiders on the wall”.
What should the nurse respond to the client?
a. “You’re having hallucination, there are no spiders in this room at all”
b. “I can see the spiders on the wall, but they are not going to hurt you”
c. “Would you like me to kill the spiders”
d. “I know you are frightened, but I do not see spiders on the wall”
Question 28 Explanation: When hallucination is present, the nurse should reinforce reality with
the client.

29) A 32 year old male graduate student, who has become increasingly withdrawn and neglectful
of his work and personal hygiene, is brought to the psychiatric hospital by his parents. After
detailed assessment, a diagnosis of schizophrenia is made. It is unlikely that the client will
demonstrate:
a. Concrete thinking
b. Low self esteem
c. Effective self boundaries
d. Weak ego
Question 29 Explanation: A person with this disorder would not have adequate self-boundaries.

30) When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates
achievement of the discharge maintenance goals. Which goal would be most appropriately
having been included in the plan of care requiring evaluation?
a. The client eliminates all anxiety from daily situations
b. The client maintains contact with a crisis counselor
c. The client identifies anxiety producing situations
d. The client ignores feelings of anxiety
Question 30 Explanation: Recognizing situations that produce anxiety allows the client to
prepare to cope with anxiety or avoid specific stimulus.

31) A 75 year old client is admitted to the hospital with the diagnosis of dementia of the
Alzheimer’s type and depression. The symptom that is unrelated to depression would be?
a. Apathetic response to the environment
b. Neglect of personal hygiene
c. Shallow of labile effect
d. “I don’t know” answer to questions
Question 31 Explanation: With depression, there is little or no emotional involvement therefore
little alteration in affect.

32) Nurse Benjie is communicating with a male client with substance-induced persisting dementia;
the client cannot remember facts and fills in the gaps with imaginary information. Nurse
Benjie is aware that this is typical of?
a. Flight of ideas
b. Confabulation
 c. Concretism
d. Associative looseness
Question 32 Explanation: Confabulation or the filling in of memory gaps with imaginary facts is a
defense mechanism used by people experiencing memory deficits.

33) Nurse Maureen is developing a plan of care for a female client with anorexia nervosa. Which
action should the nurse include in the plan?
a. Encourage client to exercise to reduce anxiety
b. Provide privacy during meals
c. Set-up a strict eating plan for the client
d. Restrict visits with the family
Question 33 Explanation: Establishing a consistent eating plan and monitoring client’s weight are
important to this disorder.

34) A characteristic that would suggest to Nurse Anne that an adolescent may have bulimia would
be:
a. Frequent regurgitation & re-swallowing of food
b. Badly stained teeth
c. Positive body image
d. Previous history of gastritis
Question 34 Explanation: Dental enamel erosion occurs from repeated self-induced vomiting.

35) Nurse Patricia is aware that the major health complication associated with intractable
anorexia nervosa would be?
a. Cardiac dysrhythmias resulting to cardiac arrest
b. Decreased metabolism causing cold intolerance
c. Glucose intolerance resulting in protracted hypoglycemi
d. Endocrine imbalance causing cold amenorrhea
Question 35 Explanation: These clients have severely depleted levels of sodium and potassium
because of their starvation diet and energy expenditure, these electrolytes are necessary for
cardiac functioning.

36) When working with a male client suffering phobia about black cats, Nurse Trish should
anticipate that a problem for this client would be?
a. Anxiety when discussing phobia
b. Denying that the phobia exist
c. Anger toward the feared object
d. Distortion of reality when completing daily routines
Question 36 Explanation: Discussion of the feared object triggers an emotional response to the
object.

37) Nurse Trish is working in a mental health facility; the nurse priority nursing intervention for a
newly admitted client with bulimia nervosa would be to?
a. Teach client to measure I & O
 b. Involve client in planning daily meal
c. Observe client during meals
d. Monitor client continuously
Question 37 Explanation: These clients often hide food or force vomiting; therefore they must
be carefully monitored.

38) Mario is admitted to the emergency room with drug-included anxiety related to over ingestion
of prescribed antipsychotic medication. The most important piece of information the nurse in
charge should obtain initially is the:
a. Length of time on the med.
b. Name of the nearest relative & their phone number
c. Reason for the suicide attempt
d. Name of the ingested medication & the amount ingested
Question 38 Explanation: In an emergency, lives saving facts are obtained first. The name and
the amount of medication ingested are of outmost important in treating this potentially life
threatening situation.

39) A 23 year old client has been admitted with a diagnosis of schizophrenia says to the nurse
“Yes, its march, March is little woman”. That’s literal you know”. These statement illustrate:
a. Loosening of association
b. Echolalia
c. Flight of ideas
d. Neologisms
Question 39 Explanation: Loose associations are thoughts that are presented without the logical
connections usually necessary for the listening to interpret the message.

40) Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor. When Nurse Nina
enters the client’s room, the client is found lying on the bed with a body pulled into a fetal
position. Nurse Nina should?
a. Leave the client alone and continue with providing care to the other clients
b. Rake the client into the dayroom to be with other clients
c. Ask the client direct questions to encourage talking
d. Sit beside the client in silence and occasionally ask open-ended question
Question 40 Explanation: 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.

41) Nurse Tony was caring for a 41 year old female client. Which behavior by the client indicates
adult cognitive development?
a. Has maximum ability to solve problems and learn new skills
b. Generates new levels of awareness
c. Assumes responsibility for her actions
d. Her perception are based on reality
 Question 41 Explanation: An adult age 31 to 45 generates new level of awareness.

42) To establish open and trusting relationship with a female client who has been hospitalized
with severe anxiety, the nurse in charge should?
a. Give client feedback about behavior
b. Share an activity with the client
c. Encourage the staff to have frequent interaction with the client
d. Respect client’s need for personal space
Question 42 Explanation: Moving to a client’s personal space increases the feeling of threat,
which increases anxiety.

43) Nurse Claire is caring for a client diagnosed with bulimia. The most appropriate initial goal for
a client diagnosed with bulimia is?
a. Eat only three meals a day
b. Encourage to avoid foods
c. Identify anxiety causing situations
d. Avoid shopping plenty of groceries
Question 43 Explanation: Bulimia disorder generally is a maladaptive coping response to stress
and underlying issues. The client should identify anxiety causing situation that stimulate the
bulimic behavior and then learn new ways of coping with the anxiety.
44) Nurse Monette is aware that extremely depressed clients seem to do best in settings where
they have:
a. Routine Activities
b. Minimal decision making
c. Multiple stimuli
d. Varied Activities
Question 44 Explanation: Depression usually is both emotional & physical. A simple daily routine
is the best, least stressful and least anxiety producing.

45) Conney with borderline personality disorder who is to be discharge soon threatens to “do
something” to herself if discharged. Which of the following actions by the nurse would be
most important?
a. Ask a family member to stay with the client at home temporarily
b. Discuss the meaning of the client’s statement with her
c. Request an immediate extension for the client
d. Ignore the clients statement because it’s a sign of manipulation
Question 45 Explanation: Any suicidal statement must be assessed by the nurse. The nurse
should discuss the client’s statement with her to determine its meaning in terms of suicide.

46) Joey a client with antisocial personality disorder belches loudly. A staff member asks Joey, “Do
you know why people find you repulsive?” this statement most likely would elicit which of the
following client reaction?
a. Shame
b. Defensiveness
 c. Remorseful
d. Embarrassment
Question 46 Explanation: When the staff member ask the client if he wonders why others find
him repulsive, the client is likely to feel defensive because the question is belittling. The natural
tendency is to counterattack the threat to self image.

47) A 39 year old mother with obsessive-compulsive disorder has become immobilized by her
elaborate hand washing and walking rituals. Nurse Trish recognizes that the basis of O.C.
disorder is often:
a. Feelings of guilt and inadequacy
b. Feeling of unworthiness and hopelessness
c. Problems with anger and remorse
d. Problems with being too conscientious
Question 47 Explanation: Ritualistic behavior seen in this disorder is aimed at controlling guilt
and inadequacy by maintaining an absolute set pattern of behavior.

48) Which of the following approaches would be most appropriate to use with a client suffering
from narcissistic personality disorder when discrepancies exist between what the client states
and what actually exist?
a. Rationalization
b. Consistency
c. Supportive confrontation
d. Limit setting
Question 48 Explanation: The nurse would specifically use supportive confrontation with the
client to point out discrepancies between what the client states and what actually exists to
increase responsibility for self.

49) Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis and hyperactivity. Blood
pressure is 190/87 mmhg and pulse is 92 bpm. Which of the medications would the nurse
expect to administer?
a. Naloxone (Narcan)
b. Benzlropine (Cogentin)
c. Lorazepam (Ativan)
d. Haloperidol (Haldol)
Question 49 Explanation: The nurse would most likely administer benzodiazepine, such as
lorazepan (ativan) to the client who is experiencing symptom: The client’s experiences
symptoms of withdrawal because of the rebound phenomenon when the sedation of the CNS
from alcohol begins to decrease.

50) Nurse Trish would expect a child with a diagnosis of reactive attachment disorder to:
a. Have been physically abuse
b. Be able to develop only superficial relation with the others
c. Cling to mother & cry on separation
d. Have more positive relation with the father than the mother
Question 50 Explanation: Children who have experienced attachment difficulties with primary
caregiver are not able to trust others and therefore relate superficially