NSG 2400 EXAM 1 EAQ QUESTIONS AND
CORRECT VERIFIED ANSWERS
The nurse notices that one of her clients, who has depression, is sitting by the window
crying. What is the most appropriate response by the nurse?
1
"It's okay. No need to cry or worry while you're here. We all feel down now and then."
2
"Please don't consider suicide. It really isn't an appropriate way out of your troubles."
3
"You seem to be experiencing a sad moment. I'll sit here with you for a while and talk if
you would like."
4
"Why don't you go into the dayroom and join the card game going on? That'll take your
mind off of your problems for a while." - Ans--3
"You seem to be experiencing a sad moment. I'll sit here with you for a while and talk if
you would like."
The nurse is acknowledging that the client is feeling especially down and offering to be
available for discussion or just to provide a presence. Telling the client not to cry and
suggesting a card game do not acknowledge the client's feelings and appear to trivialize
the situation. The response regarding suicide is judgmental and may discourage any
effort by the client to initiate a discussion.
A 20-year-old carpenter falls from a roof and sustains fractures of the right femur and
left tibia. The client reveals a history of substance abuse. What is the primary
consideration for the nurse who is caring for this client?
1
Confronting the client about substance abuse
2
Avoiding calling attention to the client's drug abuse
3
Determining the amount and time of last use of the substance
4
Realizing that this client will need more pain medication than a nonabuser - Ans--3
Determining the amount and time of last use of the substance
Determining the amount and last use of the substance is the priority. Nurses should
base their treatment of withdrawal symptoms on the time and amount of last use.
Confronting the client is not the nurse's responsibility at this time. The client must be
helped to recognize that a problem with drugs exists, but this is not the priority. Because
,of cross-tolerance the client may need larger doses of analgesia for pain relief than a
nonabuser would, but this is not the priority.
A nurse is planning care for a client admitted to the unit with a diagnosis of bipolar
disorder, manic phase. In which type of room should the nurse tell the admissions clerk
to place this client?
1
Private
2
Isolation
3
Semi-private
4
Negative-airflow - Ans--1
Private
The client who is manic needs a nonstimulating environment. A person who is bipolar is
not contagious and does not require an isolation room. The presence of another person
in the room is considered stimulating and may interfere with the rest and sleep of both
clients. A client who is bipolar does not need a negative-airflow room. This type of room
is appropriate for a client with a communicable disease, such as tuberculosis, that
requires airborne precautions.
A nurse is assigned to care for an adolescent who has been admitted to the psychiatric
hospital with a diagnosis of anorexia nervosa. What should the nurse's initial
intervention be?
1
Scheduling an endocrinology consult because of amenorrhea
2
Confronting those behaviors that reflect an inflated self-importance
3
Arranging for psychotherapy sessions to help develop a desire to accommodate others
4
Developing a contract to achieve a weekly weight gain, with consequences for
nonachievement - Ans--4
Developing a contract to achieve a weekly weight gain, with consequences for
nonachievement
Treatment usually includes a contract for weight gain, signed by the client, whereby
privileges are revoked if the weight is not gained; the diet and the amount of food eaten
are not the focus of care. Menstruation usually ceases because of severe malnutrition,
not because of endocrine pathology. These clients have a low self-esteem and usually
do not feel important.
A client in a detoxification unit has an alcohol withdrawal seizure. Diazepam 7.5 mg
intramuscularly stat is prescribed. Diazepam is available as 5 mg/mL. How many
,milliliters will the nurse administer? Record your answer using one decimal place. ___
mL - Ans--1.5
A client with a diagnosis of schizophrenia, undifferentiated type, is being admitted to the
psychiatric unit. What clinical manifestations does the nurse expect when assessing this
client? Select all that apply.
1
Excited behaviors
2
Loose associations
3
Inappropriate affect
4
Feelings of depression
5
Hypervigilant behavior - Ans--1
Excited behaviors
2
Loose associations
3
Inappropriate affect
Excited behaviors, such as aggressive hitting or biting, often are associated with an
acute onset of undifferentiated schizophrenia. Loose association is a characteristic
related to thought disorders such as schizophrenia, undifferentiated type. The affect
usually is inappropriate, rather than flat, in undifferentiated schizophrenia. Depression is
not characteristic of undifferentiated schizophrenia. Hypervigilant behaviors generally
are associated with paranoid schizophrenia, not undifferentiated schizophrenia.
A client who is in a manic phase of bipolar disorder threatens staff and clients on a
psychiatric acute care unit. Place these interventions in priority order, from the least to
the most restrictive.
1.
Diversional activities
2.
Limit-setting
3.
Medication administration
4.
Seclusion
5.
, Restraints - Ans--1,2,3,4,5
Diversional activities should be the first intervention attempted, because they do not
involve any restriction on client activities and manic clients are easily distracted. Limit-
setting should be the next intervention attempted, because it is minimally restrictive.
Medication administration, although considered a chemical restraint, is less restrictive
than physical restraints or seclusion. Seclusion is more restrictive than medication but
less restrictive than restraints. Restraints are the most restrictive intervention in
psychiatric nursing.
A client is receiving a monoamine oxidase inhibitor (MAOI). What does the nurse teach
the client?
1
It is necessary to avoid the sun.
2
Drowsiness is an expected side effect of this medication.
3
The therapeutic and toxic levels of the drug are very close.
4
Many prescribed and over-the-counter drugs cannot be taken with this medication. -
Ans--4
Many prescribed and over-the-counter drugs cannot be taken with this medication.
MAOIs interact with many other medications to produce harmful side effects. Clients
must be taught to check with the prescribing primary healthcare provider before taking
any new medications. Photosensitivity has not been reported in clients who are taking
MAOIs. Drowsiness is not an expected side effect, but it may occur as an adverse
reaction. The therapeutic and toxic levels of the drug are not close for these
medications.
A client with recurrent episodes of depression comes to the mental health clinic for a
routine follow-up visit. The nurse suspects that the client is at increased risk for suicide.
What is a contributing factor to the client's risk for suicide?
1
Psychomotor retardation
2
Decreased physical activity
3
Deliberate thoughtful behavior
4
Overwhelming feelings of guilt - Ans--4
Overwhelming feelings of guilt
Overwhelming feelings of guilt contribute to the client's risk for suicide. The client may
ruminate over past or current failings, and extreme guilt can assume psychotic
proportions. Psychomotor retardation and decreased physical activity are clinical
findings associated with depression and usually do not lead to suicide because the
CORRECT VERIFIED ANSWERS
The nurse notices that one of her clients, who has depression, is sitting by the window
crying. What is the most appropriate response by the nurse?
1
"It's okay. No need to cry or worry while you're here. We all feel down now and then."
2
"Please don't consider suicide. It really isn't an appropriate way out of your troubles."
3
"You seem to be experiencing a sad moment. I'll sit here with you for a while and talk if
you would like."
4
"Why don't you go into the dayroom and join the card game going on? That'll take your
mind off of your problems for a while." - Ans--3
"You seem to be experiencing a sad moment. I'll sit here with you for a while and talk if
you would like."
The nurse is acknowledging that the client is feeling especially down and offering to be
available for discussion or just to provide a presence. Telling the client not to cry and
suggesting a card game do not acknowledge the client's feelings and appear to trivialize
the situation. The response regarding suicide is judgmental and may discourage any
effort by the client to initiate a discussion.
A 20-year-old carpenter falls from a roof and sustains fractures of the right femur and
left tibia. The client reveals a history of substance abuse. What is the primary
consideration for the nurse who is caring for this client?
1
Confronting the client about substance abuse
2
Avoiding calling attention to the client's drug abuse
3
Determining the amount and time of last use of the substance
4
Realizing that this client will need more pain medication than a nonabuser - Ans--3
Determining the amount and time of last use of the substance
Determining the amount and last use of the substance is the priority. Nurses should
base their treatment of withdrawal symptoms on the time and amount of last use.
Confronting the client is not the nurse's responsibility at this time. The client must be
helped to recognize that a problem with drugs exists, but this is not the priority. Because
,of cross-tolerance the client may need larger doses of analgesia for pain relief than a
nonabuser would, but this is not the priority.
A nurse is planning care for a client admitted to the unit with a diagnosis of bipolar
disorder, manic phase. In which type of room should the nurse tell the admissions clerk
to place this client?
1
Private
2
Isolation
3
Semi-private
4
Negative-airflow - Ans--1
Private
The client who is manic needs a nonstimulating environment. A person who is bipolar is
not contagious and does not require an isolation room. The presence of another person
in the room is considered stimulating and may interfere with the rest and sleep of both
clients. A client who is bipolar does not need a negative-airflow room. This type of room
is appropriate for a client with a communicable disease, such as tuberculosis, that
requires airborne precautions.
A nurse is assigned to care for an adolescent who has been admitted to the psychiatric
hospital with a diagnosis of anorexia nervosa. What should the nurse's initial
intervention be?
1
Scheduling an endocrinology consult because of amenorrhea
2
Confronting those behaviors that reflect an inflated self-importance
3
Arranging for psychotherapy sessions to help develop a desire to accommodate others
4
Developing a contract to achieve a weekly weight gain, with consequences for
nonachievement - Ans--4
Developing a contract to achieve a weekly weight gain, with consequences for
nonachievement
Treatment usually includes a contract for weight gain, signed by the client, whereby
privileges are revoked if the weight is not gained; the diet and the amount of food eaten
are not the focus of care. Menstruation usually ceases because of severe malnutrition,
not because of endocrine pathology. These clients have a low self-esteem and usually
do not feel important.
A client in a detoxification unit has an alcohol withdrawal seizure. Diazepam 7.5 mg
intramuscularly stat is prescribed. Diazepam is available as 5 mg/mL. How many
,milliliters will the nurse administer? Record your answer using one decimal place. ___
mL - Ans--1.5
A client with a diagnosis of schizophrenia, undifferentiated type, is being admitted to the
psychiatric unit. What clinical manifestations does the nurse expect when assessing this
client? Select all that apply.
1
Excited behaviors
2
Loose associations
3
Inappropriate affect
4
Feelings of depression
5
Hypervigilant behavior - Ans--1
Excited behaviors
2
Loose associations
3
Inappropriate affect
Excited behaviors, such as aggressive hitting or biting, often are associated with an
acute onset of undifferentiated schizophrenia. Loose association is a characteristic
related to thought disorders such as schizophrenia, undifferentiated type. The affect
usually is inappropriate, rather than flat, in undifferentiated schizophrenia. Depression is
not characteristic of undifferentiated schizophrenia. Hypervigilant behaviors generally
are associated with paranoid schizophrenia, not undifferentiated schizophrenia.
A client who is in a manic phase of bipolar disorder threatens staff and clients on a
psychiatric acute care unit. Place these interventions in priority order, from the least to
the most restrictive.
1.
Diversional activities
2.
Limit-setting
3.
Medication administration
4.
Seclusion
5.
, Restraints - Ans--1,2,3,4,5
Diversional activities should be the first intervention attempted, because they do not
involve any restriction on client activities and manic clients are easily distracted. Limit-
setting should be the next intervention attempted, because it is minimally restrictive.
Medication administration, although considered a chemical restraint, is less restrictive
than physical restraints or seclusion. Seclusion is more restrictive than medication but
less restrictive than restraints. Restraints are the most restrictive intervention in
psychiatric nursing.
A client is receiving a monoamine oxidase inhibitor (MAOI). What does the nurse teach
the client?
1
It is necessary to avoid the sun.
2
Drowsiness is an expected side effect of this medication.
3
The therapeutic and toxic levels of the drug are very close.
4
Many prescribed and over-the-counter drugs cannot be taken with this medication. -
Ans--4
Many prescribed and over-the-counter drugs cannot be taken with this medication.
MAOIs interact with many other medications to produce harmful side effects. Clients
must be taught to check with the prescribing primary healthcare provider before taking
any new medications. Photosensitivity has not been reported in clients who are taking
MAOIs. Drowsiness is not an expected side effect, but it may occur as an adverse
reaction. The therapeutic and toxic levels of the drug are not close for these
medications.
A client with recurrent episodes of depression comes to the mental health clinic for a
routine follow-up visit. The nurse suspects that the client is at increased risk for suicide.
What is a contributing factor to the client's risk for suicide?
1
Psychomotor retardation
2
Decreased physical activity
3
Deliberate thoughtful behavior
4
Overwhelming feelings of guilt - Ans--4
Overwhelming feelings of guilt
Overwhelming feelings of guilt contribute to the client's risk for suicide. The client may
ruminate over past or current failings, and extreme guilt can assume psychotic
proportions. Psychomotor retardation and decreased physical activity are clinical
findings associated with depression and usually do not lead to suicide because the
