A child was abducted and raped. Which personal reaction by the nurse could interfere
with the childs care?
a. Anger
b. Concern
c. Empathy
d. Compassion - ansa
A cognitively impaired patient has been a widow for 30 years. This patient is frantically
trying to leave the unit, saying, I have to go home to cook dinner before my husband
arrives from work. To intervene with validation therapy, the nurse should first say:
a. You must come away from the door.
b. You have been a widow for many years.
c. You want to go home to prepare your husbands dinner?
d. Was your husband angry if you did not have dinner ready on time? - ansc
A community mental health nurse wants to establish a relationship with a very
withdrawn patient diagnosed with schizophrenia. The patient lives at home with a
supportive family. Select the nurses best plan.
a. Visit daily for 4 days, then visit every other day for 1 week; stay with the patient for 20
minutes; accept silence; state when the nurse will return.
b. Arrange to spend 1 hour each day with the patient; focus on asking questions about
what the patient is thinking or experiencing; avoid silences.
c. Visit twice daily; sit beside the patient with a hand on the patients arm; leave if the
patient does not respond within 10 minutes.
d. Visit every other day; remind the patient of the nurses identity; encourage the patient
to talk while the nurse works on reports. - ansa
A confused older adult patient in a skilled care facility is sleeping. The nurse enters the
room quietly and touches the bed to see if it is wet. The patient awakens and hits the
nurse in the face. Which statement best explains the patients action?
a. Older adult patients often demonstrate exaggerations of behaviors used earlier in life.
b. Crowding in skilled care facilities increases individual tendencies toward violence.
c. The patient interpreted the health care workers behavior as potentially harmful.
d. This patient learned violent behavior by watching other patients act out. - ansc
A disheveled patient with severe depression and psychomotor retardation has not
bathed for several days. The nurse should:
a. avoid forcing the issue.
b. bring up the issue at the community meeting.
c. calmly tell the patient, You must bathe daily.
d. firmly and neutrally assist the patient with showering. - ansd
A health care provider considers which antipsychotic medication to prescribe for a
patient diagnosed with schizophrenia who has auditory hallucinations and poor social
,functioning. The patient is also overweight and has hypertension. Which drug should the
nurse advocate?
a. clozapine (Clozaril)
b. ziprasidone (Geodon)
c. olanzapine (Zyprexa)
d. aripiprazole (Abilify) - ansd
A health teaching plan for a patient taking lithium should include instructions to:
a. maintain normal salt and fluids in the diet.
b. drink twice the usual daily amount of fluids.
c. double the lithium dose if diarrhea or vomiting occurs.
d. avoid eating aged cheese, processed meats, and red wine. - ansa
A new patient immediately requires seclusion on admission. The assessment is
incomplete, and no prescriptions have been written. Immediately after safely secluding
the patient, which action has priority?
a. Provide an opportunity for the patient to go to the bathroom.
b. Notify the health care provider and obtain a seclusion order.
c. Notify the hospital risk manager.
d. Debrief the staff. - ansb
A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly
scans the environment. The patient states, I saw two doctors talking in the hall. They
were plotting to kill me. The nurse may correctly assess this behavior as:
a. echolalia.
b. an idea of reference.
c. a delusion of infidelity.
d. an auditory hallucination. - ansb
A newly admitted patient diagnosed with schizophrenia says, The voices are bothering
me. They yell and tell me Im bad. I have got to get away from them. Select the nurses
most helpful reply.
a. Do you hear the voices often?
b. Do you have a plan for getting away from the voices?
c. I will stay with you. Focus on what we are talking about, not the voices.
d. Forget the voices. Ask some other patients to sit and talk with you. - ansc
A nurse cares for a rape victim who was given flunitrazepam (Rohypnol) by the
assailant. Which intervention has priority? Monitoring for:
a. coma.
b. seizures.
c. hypotonia.
d. respiratory depression. - ansd
A nurse conducting group therapy on the eating disorders unit schedules the sessions
immediately after meals for the primary purpose of:
,a. maintaining patients concentration and attention.
b. shifting the patients focus from food to psychotherapy.
c. focusing on weight control mechanisms and food preparation.
d. processing the heightened anxiety associated with eating. - ansd
A nurse in the emergency department tells an adult, Your mother had a severe stroke.
The adult tearfully says, Who will take care of me now? My mother always told me what
to do, what to wear, and what to eat. I need someone to reassure me when I get
anxious. Which term best describes this behavior?
a. Histrionic
b. Dependent
c. Narcissistic
d. Borderline - ansb
A nurse instructs a patient taking a drug that inhibits the action of monoamine oxidase
(MAO) to avoid certain foods and drugs because of the risk of:
a. hypotensive shock.
b. hypertensive crisis.
c. cardiac dysrhythmia.
d. cardiogenic shock. - ansb
A nurse interviews a person abducted and raped at gunpoint by an unknown assailant.
The person says, I cant talk about it. Nothing happened. I have to forget! What is the
persons present coping strategy?
a. Somatic reaction
b. Repression
c. Projection
d. Denial - ansd
A nurse is caring for a patient with low self-esteem. Which nonverbal communication
should the nurse anticipate?
a. Arms crossed
b. Staring at the nurse
c. Smiling inappropriately
d. Eyes pointed downward - ansd
A nurse observes a patient who is diagnosed with schizophrenia. The patient is
standing immobile, facing the wall with one arm extended in a salute. The patient
remains immobile in this position for 15 minutes, moving only when the nurse gently
lowers the arm. What is the name of this phenomenon?
a. Echolalia
b. Waxy flexibility
c. Depersonalization
d. Thought withdrawal - ansb
, A nurse provided medication education for a patient who takes phenelzine (Nardil) for
depression. Which behavior indicates effective learning? The patient:
a. monitors sodium intake and weight daily.
b. wears support stockings and elevates the legs when sitting.
c. consults the pharmacist when selecting over-the-counter medications.
d. can identify foods with high selenium content, which should be avoided. - ansc
A nurse receives this laboratory result for a patient diagnosed with bipolar disorder:
lithium level 1 mEq/L. This result is:
a. within therapeutic limits
b. below therapeutic limits
c. above therapeutic limits
d. incorrect because of inaccurate testing - ansa
A nurse reports to the interdisciplinary team that a patient diagnosed with an antisocial
personality disorder lies to other patients, verbally abuses a patient diagnosed with
dementia, and flatters the primary nurse. This patient is detached and superficial during
counseling sessions. Which behavior most clearly warrants limit setting?
a. Flattering the nurse
b. Lying to other patients
c. Verbal abuse of another patient
d. Detached superficiality during counseling - ansc
A nurse set limits for a patient diagnosed with a borderline personality disorder. The
patient tells the nurse, You used to care about me. I thought you were wonderful. Now I
can see I was mistaken. Youre terrible. This outburst can be assessed as:
a. denial.
b. splitting.
c. reaction formation.
d. separation-individuation strategies. - ansb
A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh
uncontrollably, although the nurse has not said anything funny. Select the nurses best
response.
a. Why are you laughing?
b. Please share the joke with me.
c. I dont think I said anything funny.
d. You are laughing. Tell me whats happening. - ansd
A nurse teaching a patient about a tyramine-restricted diet would approve which meal?
a. Mashed potatoes, ground beef patty, corn, green beans, apple pie
b. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake
c. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee
d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls -
ansa
with the childs care?
a. Anger
b. Concern
c. Empathy
d. Compassion - ansa
A cognitively impaired patient has been a widow for 30 years. This patient is frantically
trying to leave the unit, saying, I have to go home to cook dinner before my husband
arrives from work. To intervene with validation therapy, the nurse should first say:
a. You must come away from the door.
b. You have been a widow for many years.
c. You want to go home to prepare your husbands dinner?
d. Was your husband angry if you did not have dinner ready on time? - ansc
A community mental health nurse wants to establish a relationship with a very
withdrawn patient diagnosed with schizophrenia. The patient lives at home with a
supportive family. Select the nurses best plan.
a. Visit daily for 4 days, then visit every other day for 1 week; stay with the patient for 20
minutes; accept silence; state when the nurse will return.
b. Arrange to spend 1 hour each day with the patient; focus on asking questions about
what the patient is thinking or experiencing; avoid silences.
c. Visit twice daily; sit beside the patient with a hand on the patients arm; leave if the
patient does not respond within 10 minutes.
d. Visit every other day; remind the patient of the nurses identity; encourage the patient
to talk while the nurse works on reports. - ansa
A confused older adult patient in a skilled care facility is sleeping. The nurse enters the
room quietly and touches the bed to see if it is wet. The patient awakens and hits the
nurse in the face. Which statement best explains the patients action?
a. Older adult patients often demonstrate exaggerations of behaviors used earlier in life.
b. Crowding in skilled care facilities increases individual tendencies toward violence.
c. The patient interpreted the health care workers behavior as potentially harmful.
d. This patient learned violent behavior by watching other patients act out. - ansc
A disheveled patient with severe depression and psychomotor retardation has not
bathed for several days. The nurse should:
a. avoid forcing the issue.
b. bring up the issue at the community meeting.
c. calmly tell the patient, You must bathe daily.
d. firmly and neutrally assist the patient with showering. - ansd
A health care provider considers which antipsychotic medication to prescribe for a
patient diagnosed with schizophrenia who has auditory hallucinations and poor social
,functioning. The patient is also overweight and has hypertension. Which drug should the
nurse advocate?
a. clozapine (Clozaril)
b. ziprasidone (Geodon)
c. olanzapine (Zyprexa)
d. aripiprazole (Abilify) - ansd
A health teaching plan for a patient taking lithium should include instructions to:
a. maintain normal salt and fluids in the diet.
b. drink twice the usual daily amount of fluids.
c. double the lithium dose if diarrhea or vomiting occurs.
d. avoid eating aged cheese, processed meats, and red wine. - ansa
A new patient immediately requires seclusion on admission. The assessment is
incomplete, and no prescriptions have been written. Immediately after safely secluding
the patient, which action has priority?
a. Provide an opportunity for the patient to go to the bathroom.
b. Notify the health care provider and obtain a seclusion order.
c. Notify the hospital risk manager.
d. Debrief the staff. - ansb
A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly
scans the environment. The patient states, I saw two doctors talking in the hall. They
were plotting to kill me. The nurse may correctly assess this behavior as:
a. echolalia.
b. an idea of reference.
c. a delusion of infidelity.
d. an auditory hallucination. - ansb
A newly admitted patient diagnosed with schizophrenia says, The voices are bothering
me. They yell and tell me Im bad. I have got to get away from them. Select the nurses
most helpful reply.
a. Do you hear the voices often?
b. Do you have a plan for getting away from the voices?
c. I will stay with you. Focus on what we are talking about, not the voices.
d. Forget the voices. Ask some other patients to sit and talk with you. - ansc
A nurse cares for a rape victim who was given flunitrazepam (Rohypnol) by the
assailant. Which intervention has priority? Monitoring for:
a. coma.
b. seizures.
c. hypotonia.
d. respiratory depression. - ansd
A nurse conducting group therapy on the eating disorders unit schedules the sessions
immediately after meals for the primary purpose of:
,a. maintaining patients concentration and attention.
b. shifting the patients focus from food to psychotherapy.
c. focusing on weight control mechanisms and food preparation.
d. processing the heightened anxiety associated with eating. - ansd
A nurse in the emergency department tells an adult, Your mother had a severe stroke.
The adult tearfully says, Who will take care of me now? My mother always told me what
to do, what to wear, and what to eat. I need someone to reassure me when I get
anxious. Which term best describes this behavior?
a. Histrionic
b. Dependent
c. Narcissistic
d. Borderline - ansb
A nurse instructs a patient taking a drug that inhibits the action of monoamine oxidase
(MAO) to avoid certain foods and drugs because of the risk of:
a. hypotensive shock.
b. hypertensive crisis.
c. cardiac dysrhythmia.
d. cardiogenic shock. - ansb
A nurse interviews a person abducted and raped at gunpoint by an unknown assailant.
The person says, I cant talk about it. Nothing happened. I have to forget! What is the
persons present coping strategy?
a. Somatic reaction
b. Repression
c. Projection
d. Denial - ansd
A nurse is caring for a patient with low self-esteem. Which nonverbal communication
should the nurse anticipate?
a. Arms crossed
b. Staring at the nurse
c. Smiling inappropriately
d. Eyes pointed downward - ansd
A nurse observes a patient who is diagnosed with schizophrenia. The patient is
standing immobile, facing the wall with one arm extended in a salute. The patient
remains immobile in this position for 15 minutes, moving only when the nurse gently
lowers the arm. What is the name of this phenomenon?
a. Echolalia
b. Waxy flexibility
c. Depersonalization
d. Thought withdrawal - ansb
, A nurse provided medication education for a patient who takes phenelzine (Nardil) for
depression. Which behavior indicates effective learning? The patient:
a. monitors sodium intake and weight daily.
b. wears support stockings and elevates the legs when sitting.
c. consults the pharmacist when selecting over-the-counter medications.
d. can identify foods with high selenium content, which should be avoided. - ansc
A nurse receives this laboratory result for a patient diagnosed with bipolar disorder:
lithium level 1 mEq/L. This result is:
a. within therapeutic limits
b. below therapeutic limits
c. above therapeutic limits
d. incorrect because of inaccurate testing - ansa
A nurse reports to the interdisciplinary team that a patient diagnosed with an antisocial
personality disorder lies to other patients, verbally abuses a patient diagnosed with
dementia, and flatters the primary nurse. This patient is detached and superficial during
counseling sessions. Which behavior most clearly warrants limit setting?
a. Flattering the nurse
b. Lying to other patients
c. Verbal abuse of another patient
d. Detached superficiality during counseling - ansc
A nurse set limits for a patient diagnosed with a borderline personality disorder. The
patient tells the nurse, You used to care about me. I thought you were wonderful. Now I
can see I was mistaken. Youre terrible. This outburst can be assessed as:
a. denial.
b. splitting.
c. reaction formation.
d. separation-individuation strategies. - ansb
A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh
uncontrollably, although the nurse has not said anything funny. Select the nurses best
response.
a. Why are you laughing?
b. Please share the joke with me.
c. I dont think I said anything funny.
d. You are laughing. Tell me whats happening. - ansd
A nurse teaching a patient about a tyramine-restricted diet would approve which meal?
a. Mashed potatoes, ground beef patty, corn, green beans, apple pie
b. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake
c. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee
d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls -
ansa
