1.A client is fearful of driving and enters a behavioral
therapy program to help him overcome his anxiety.
Using systematic desensitization, he is able to drive
down a familiar street without experiencing a panic
attack. The nurse should recognize that to continue
positive results, the client should participate in which of
the following?
a.Biofeedback
b.Therapist modeling
c. Frequent pacing
d.Positive reinforcement - correct answers - a.
Biofeedback
2.A nurse is counseling a client following the death of
the client's partner 8 months ago. Which of the
following client statements indicates maladaptive
grieving?
a."I am so sorry for the times I was angry with my
partner."
b."I like looking at his personal items in the closet."
c. "I find myself thinking about my partner often."
d."I still don't feel up to returning to work." - correct answers - d. "I still
don't feel up to returning to work."
Rationale: 8 months too long Maladaptive Grief: . Distorted or
exaggerated grief response - unable to
perform activities of daily living.
RISK FACTORS FOR MALADAPTIVE GRIEVING
●● Being dependent upon the deceased
●● Unexpected death at a young age, through violence, or by a socially
unacceptable manner
●● Inadequate coping skills or lack of social support
●● Pre-existing mental health issues, such as depression or substance
use disorder
3. /21 A nurse in an inpatient mental health facility is
assessing a client who has schizophrenia and is taking
haloperidol (antipsychotic, 1st gen).
Which of the following clinical findings is the nurse's
priority?
a.Headache
b.Insomnia (sedation)
,c. Urinary hesitancy (Complication → ANTIcholinergic effects)
d. High fever (Complication → agranulocytosis) - correct answers - d.
High fever (Complication → agranulocytosis)
Other complications: Acute dystonia, Pseudoparkinsonism,
Akathisia, Tardive dyskinesia,
Neuroendocrine effects (Gynecomastia, Weight gain, Menstrual
irregularities), NMS, Orthostatic Hypotension, Sedation, Sexual
dysfunction, Skin effects, Liver impairment
4.A nurse is planning care for a client who has
obsessive compulsive disorder. Which of the following
recommendations should the nurse include in the
client's plan of care?
a.Reality Orientation therapy (re-orient to reality)
b.Operant Conditioning (receives positive rewards for
positive behavior)
c.Thought Stopping (say "stop" when compulsive behaviors arise
& substitute w/ positive thought)
d.Validation Therapy (acknowledging pt's feelings) - correct answers -
c.
5. Thought
A nurse isStopping (say
caring for "stop"who
a client when compulsive
is in the manicbehaviors arise &
substitute
phase of bipolar disorder. Which of the following
w/ positive
actions thought)
should the nurse take?
a.Provide in depth explanation of nursing
expectations (inability to focus - give concise
explanations)
b.Encourage the client to participate in group
activities (decrease stimulation)
c.Avoid power struggles by remaining neutral (do
not react personally to pt's comments) - correct
d.Allow the client to set limits for his behavior answers
(nurse sets limits)
- c. Avoid power struggles by remaining neutral (do
not react
6.A nursepersonally to pt's
is providing comments)
behavioral therapy for a client
who has OCD. The client repeatedly checks that the
doors are locked at night. Which of the following
instructions should the nurse give the client when
using thought stopping technique?
a."Keep a journal of how often you check the
locks each night."
b."Ask a family member to check the locks for
you at night."
c."Focus on abdominal breathing whenever
you go to check the locks."
d."Snap a rubber band on your wrist when
you think about
, checking the locks." - correct answers - d. "Snap a rubber band on your
wrist when you think about
checking the locks."
Thought stopping: teach pt to say "stop" when negative
thoughts/compulsive behaviors arise & substitute positive thought -
goal forpt use command silently over time
7. A nurse is caring for a client who has a cocaine use
disorder. Which of the following manifestations should
the nurse expect the client to have during withdrawal?
a.Hand tremors (Intoxication)
b.Fatigue
c. Seizures (Intoxication)
d.Rapid speech
Rationale: Pg: 97 WITHDRAWAL MANIFESTATIONS● Depression,
fatigue, craving, excess sleeping or
insomnia, dramatic unpleasant dreams, psychomotor retardation, agitation
● Not life- threatening, but
possible occurrence of suicidal ideation
Cocaine = STIMULANT → OPPOSITE of
HEROIN
●Withdrawal = opposite effects -
correct answers - b. Fatigue
8. A nurse is reviewing the medical record of a client who
is taking clozapine. For which of the following findings
should the nurse withhold the medication and notify the
provider?
e.WBC count
f. Heart rate
g.Report of photosensitivity
h.Blood glucose level - correct answers - a. WBC count
9. /59. A nurse is creating a plan of care for a client
who has major depressive disorder. Which of the
following interventions should the nurse include in the
plan?
a.Keep the ring light on in the client's room at night
b.Encourage physical activity for the client during the
day
c.Identity and schedule alternative group
activities for the client
d.Discourage the client from expressing feeling of anger - correct
answers - b. Encourage physical activity for the client during the day
10. A nurse is assessing a client who is experiencing
acute alcohol withdrawal. Which of the following
findings should the
therapy program to help him overcome his anxiety.
Using systematic desensitization, he is able to drive
down a familiar street without experiencing a panic
attack. The nurse should recognize that to continue
positive results, the client should participate in which of
the following?
a.Biofeedback
b.Therapist modeling
c. Frequent pacing
d.Positive reinforcement - correct answers - a.
Biofeedback
2.A nurse is counseling a client following the death of
the client's partner 8 months ago. Which of the
following client statements indicates maladaptive
grieving?
a."I am so sorry for the times I was angry with my
partner."
b."I like looking at his personal items in the closet."
c. "I find myself thinking about my partner often."
d."I still don't feel up to returning to work." - correct answers - d. "I still
don't feel up to returning to work."
Rationale: 8 months too long Maladaptive Grief: . Distorted or
exaggerated grief response - unable to
perform activities of daily living.
RISK FACTORS FOR MALADAPTIVE GRIEVING
●● Being dependent upon the deceased
●● Unexpected death at a young age, through violence, or by a socially
unacceptable manner
●● Inadequate coping skills or lack of social support
●● Pre-existing mental health issues, such as depression or substance
use disorder
3. /21 A nurse in an inpatient mental health facility is
assessing a client who has schizophrenia and is taking
haloperidol (antipsychotic, 1st gen).
Which of the following clinical findings is the nurse's
priority?
a.Headache
b.Insomnia (sedation)
,c. Urinary hesitancy (Complication → ANTIcholinergic effects)
d. High fever (Complication → agranulocytosis) - correct answers - d.
High fever (Complication → agranulocytosis)
Other complications: Acute dystonia, Pseudoparkinsonism,
Akathisia, Tardive dyskinesia,
Neuroendocrine effects (Gynecomastia, Weight gain, Menstrual
irregularities), NMS, Orthostatic Hypotension, Sedation, Sexual
dysfunction, Skin effects, Liver impairment
4.A nurse is planning care for a client who has
obsessive compulsive disorder. Which of the following
recommendations should the nurse include in the
client's plan of care?
a.Reality Orientation therapy (re-orient to reality)
b.Operant Conditioning (receives positive rewards for
positive behavior)
c.Thought Stopping (say "stop" when compulsive behaviors arise
& substitute w/ positive thought)
d.Validation Therapy (acknowledging pt's feelings) - correct answers -
c.
5. Thought
A nurse isStopping (say
caring for "stop"who
a client when compulsive
is in the manicbehaviors arise &
substitute
phase of bipolar disorder. Which of the following
w/ positive
actions thought)
should the nurse take?
a.Provide in depth explanation of nursing
expectations (inability to focus - give concise
explanations)
b.Encourage the client to participate in group
activities (decrease stimulation)
c.Avoid power struggles by remaining neutral (do
not react personally to pt's comments) - correct
d.Allow the client to set limits for his behavior answers
(nurse sets limits)
- c. Avoid power struggles by remaining neutral (do
not react
6.A nursepersonally to pt's
is providing comments)
behavioral therapy for a client
who has OCD. The client repeatedly checks that the
doors are locked at night. Which of the following
instructions should the nurse give the client when
using thought stopping technique?
a."Keep a journal of how often you check the
locks each night."
b."Ask a family member to check the locks for
you at night."
c."Focus on abdominal breathing whenever
you go to check the locks."
d."Snap a rubber band on your wrist when
you think about
, checking the locks." - correct answers - d. "Snap a rubber band on your
wrist when you think about
checking the locks."
Thought stopping: teach pt to say "stop" when negative
thoughts/compulsive behaviors arise & substitute positive thought -
goal forpt use command silently over time
7. A nurse is caring for a client who has a cocaine use
disorder. Which of the following manifestations should
the nurse expect the client to have during withdrawal?
a.Hand tremors (Intoxication)
b.Fatigue
c. Seizures (Intoxication)
d.Rapid speech
Rationale: Pg: 97 WITHDRAWAL MANIFESTATIONS● Depression,
fatigue, craving, excess sleeping or
insomnia, dramatic unpleasant dreams, psychomotor retardation, agitation
● Not life- threatening, but
possible occurrence of suicidal ideation
Cocaine = STIMULANT → OPPOSITE of
HEROIN
●Withdrawal = opposite effects -
correct answers - b. Fatigue
8. A nurse is reviewing the medical record of a client who
is taking clozapine. For which of the following findings
should the nurse withhold the medication and notify the
provider?
e.WBC count
f. Heart rate
g.Report of photosensitivity
h.Blood glucose level - correct answers - a. WBC count
9. /59. A nurse is creating a plan of care for a client
who has major depressive disorder. Which of the
following interventions should the nurse include in the
plan?
a.Keep the ring light on in the client's room at night
b.Encourage physical activity for the client during the
day
c.Identity and schedule alternative group
activities for the client
d.Discourage the client from expressing feeling of anger - correct
answers - b. Encourage physical activity for the client during the day
10. A nurse is assessing a client who is experiencing
acute alcohol withdrawal. Which of the following
findings should the
