NUR 354 Exam 4 NCLEX UPDATED
ACTUAL Questions and CORRECT
Answers
What priority nursing assessments should be made early in the refeeding process for a patient with
anorexia nervosa? Select all that apply:
a. Vital Signs
b. Skin Integrity
c. Peripheral Edema
d. Lung and Heart Sounds
e. Level of Consciousness - CORRECT ANSWER -a. Vital Signs
c. Peripheral Edema
d. Lung and Heart Sounds
A nurse anticipates that most clients with phobias will use the defense mechanisms of:
a. Dissociation and denial
b. Introjection and sublimation
c. Projection and displacement
d. Substitution and reaction formation - CORRECT ANSWER -c. Projection and displacement
Clients with phobias cope with anxiety by placing it on specific persons, objects, or situations through the
process of displacement and/or projection. The person with a phobia recognizes and admits the
exaggerated fear as a real part of the self. Neither introjection, whereby a person internalizes and
incorporates the traits of another, nor sublimation, whereby socially acceptable behavior is substituted for
unacceptable instincts, is related to phobic activity. A less-valued object is not substituted for one more
highly valued (substitution) nor are the expressed feelings opposite to the experienced feelings of fear
(reaction formation).
An initial step in the nurse-patient relationship for a patient diagnosed with anorexia nervosa should be:
a. Formulate the nurse-patient contract
,b. Exclude the family from the initial phase of treatment
c. Recommend a therapeutic group
d. Use intense communication - CORRECT ANSWER -a. Formulate the nurse-patient contract
The nurse-patient contract is very important with this eating disorder, and must be established early on in
treatment as one of the primary steps.
What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently
manipulates others? The patient will:
a. Identify when feeling angry
b. Use manipulation only to get needs met
c. Acknowledge manipulative behavior when it is called to his or her attention.
d. Accept fulfillment of his or her requests within an hour rather than immediately. - CORRECT
ANSWER -c. Acknowledge manipulative behavior when it is called to his or her attention.
The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if
the nurse hears the wife make which statement?
a. "I no longer feel that I deserve the beatings my husband inflicts on me."
b. "My attendance at the meetings has helped me to see that I provoke my husband's violence."
c. "I enjoy attending the meetings because they get me out of the house and away from my husband."
d. "I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics."
- CORRECT ANSWER -a. "I no longer feel that I deserve the beatings my husband inflicts on me."
Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn
what to expect and to obtain excellent pointers about successful behavioral changes. The correct option is
the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible
for his behavior and cannot be allowed to blame family members for loss of control. Option b is incorrect
because the nonalcoholic partner should not feel responsible when the spouse loses control. Option c
indicates that the group is viewed as an escape, not as a place to work on issues. Option d indicates that
the wife remains codependent.
Focus on the subject the therapeutic effect of attending an Al-Anon group. Noting the words benefiting
from attending an Al-Anon group will direct you to the correct option.
, Which finding indicates that a patient diagnosed with anorexia nervosa has met a major objective goal of
psychotherapeutic management?
a. The patient's residual volume is less than 30mL after tube feedings
b. The patient states "I am no longer afraid of gaining weight"
c. The patient reads cookbooks and plans nutritious meals
d. The patient weighs 90% of Ideal/Average Body Weight - CORRECT ANSWER -d. The patient
weighs 90% of Ideal/Average Body Weight
This is an objective measure, and always a major goal of psychotherapeutic management for this eating
disorder.
The nurse interviews a patient who restricts food and is 25% underweight. The patient says, "I still need
to lose weight. I'm not thin enough." The patient is using which defense mechanism?
a. Rationalization
b. Projection
c. Denial
d. Splitting - CORRECT ANSWER -c. Denial
The patient is in denial of the true nature of their weight and health status, unable to accept the actual
reality of the situation.
A nurse planning care for a patient diagnosed with bulimia nervosa should recommend the use of:
a. Pharmacotherapy
b. Cognitive-Behavioral Therapy
c. Psychodynamic group therapy
d. Rational Emotive Behavioral Therapy - CORRECT ANSWER -b. Cognitive-Behavioral Therapy
Cognitive-Behavioral therapy is indicated in the treatment of this eating disorder. While pharmacologic
therapy may also be helpful, the nurse is not qualified to make this recommendation unless he/she is an
ACTUAL Questions and CORRECT
Answers
What priority nursing assessments should be made early in the refeeding process for a patient with
anorexia nervosa? Select all that apply:
a. Vital Signs
b. Skin Integrity
c. Peripheral Edema
d. Lung and Heart Sounds
e. Level of Consciousness - CORRECT ANSWER -a. Vital Signs
c. Peripheral Edema
d. Lung and Heart Sounds
A nurse anticipates that most clients with phobias will use the defense mechanisms of:
a. Dissociation and denial
b. Introjection and sublimation
c. Projection and displacement
d. Substitution and reaction formation - CORRECT ANSWER -c. Projection and displacement
Clients with phobias cope with anxiety by placing it on specific persons, objects, or situations through the
process of displacement and/or projection. The person with a phobia recognizes and admits the
exaggerated fear as a real part of the self. Neither introjection, whereby a person internalizes and
incorporates the traits of another, nor sublimation, whereby socially acceptable behavior is substituted for
unacceptable instincts, is related to phobic activity. A less-valued object is not substituted for one more
highly valued (substitution) nor are the expressed feelings opposite to the experienced feelings of fear
(reaction formation).
An initial step in the nurse-patient relationship for a patient diagnosed with anorexia nervosa should be:
a. Formulate the nurse-patient contract
,b. Exclude the family from the initial phase of treatment
c. Recommend a therapeutic group
d. Use intense communication - CORRECT ANSWER -a. Formulate the nurse-patient contract
The nurse-patient contract is very important with this eating disorder, and must be established early on in
treatment as one of the primary steps.
What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently
manipulates others? The patient will:
a. Identify when feeling angry
b. Use manipulation only to get needs met
c. Acknowledge manipulative behavior when it is called to his or her attention.
d. Accept fulfillment of his or her requests within an hour rather than immediately. - CORRECT
ANSWER -c. Acknowledge manipulative behavior when it is called to his or her attention.
The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if
the nurse hears the wife make which statement?
a. "I no longer feel that I deserve the beatings my husband inflicts on me."
b. "My attendance at the meetings has helped me to see that I provoke my husband's violence."
c. "I enjoy attending the meetings because they get me out of the house and away from my husband."
d. "I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics."
- CORRECT ANSWER -a. "I no longer feel that I deserve the beatings my husband inflicts on me."
Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn
what to expect and to obtain excellent pointers about successful behavioral changes. The correct option is
the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible
for his behavior and cannot be allowed to blame family members for loss of control. Option b is incorrect
because the nonalcoholic partner should not feel responsible when the spouse loses control. Option c
indicates that the group is viewed as an escape, not as a place to work on issues. Option d indicates that
the wife remains codependent.
Focus on the subject the therapeutic effect of attending an Al-Anon group. Noting the words benefiting
from attending an Al-Anon group will direct you to the correct option.
, Which finding indicates that a patient diagnosed with anorexia nervosa has met a major objective goal of
psychotherapeutic management?
a. The patient's residual volume is less than 30mL after tube feedings
b. The patient states "I am no longer afraid of gaining weight"
c. The patient reads cookbooks and plans nutritious meals
d. The patient weighs 90% of Ideal/Average Body Weight - CORRECT ANSWER -d. The patient
weighs 90% of Ideal/Average Body Weight
This is an objective measure, and always a major goal of psychotherapeutic management for this eating
disorder.
The nurse interviews a patient who restricts food and is 25% underweight. The patient says, "I still need
to lose weight. I'm not thin enough." The patient is using which defense mechanism?
a. Rationalization
b. Projection
c. Denial
d. Splitting - CORRECT ANSWER -c. Denial
The patient is in denial of the true nature of their weight and health status, unable to accept the actual
reality of the situation.
A nurse planning care for a patient diagnosed with bulimia nervosa should recommend the use of:
a. Pharmacotherapy
b. Cognitive-Behavioral Therapy
c. Psychodynamic group therapy
d. Rational Emotive Behavioral Therapy - CORRECT ANSWER -b. Cognitive-Behavioral Therapy
Cognitive-Behavioral therapy is indicated in the treatment of this eating disorder. While pharmacologic
therapy may also be helpful, the nurse is not qualified to make this recommendation unless he/she is an
