PNH301 Final Part 2 | Questions & Answers
Scored A+ | Psychiatric Nursing Study Guide
Question 1: A client with osteoporosis is at highest risk for which complication?
A) Hypertension
B) Pathological fractures
C) Diabetes mellitus
D) Skin breakdown
Correct Answer: B) Pathological fractures
Explanation: Osteoporosis causes decreased bone density and structural deterioration of bone
tissue, leading to increased fragility and susceptibility to fractures, especially in the hip, spine, and
wrist.
Question 2: Which assessment finding would the nurse expect in a client with meningitis?
A) Flexion of hips and knees with passive neck flexion (positive Brudzinski's sign)
B) Hyperextension of the neck
C) Decreased deep tendon reflexes
D) Dilated pupils
Correct Answer: A) Flexion of hips and knees with passive neck flexion (positive Brudzinski's sign)
Explanation: Brudzinski's sign is a pathognomonic sign of meningitis where passive flexion of the
neck causes involuntary flexion of the hips and knees due to meningeal irritation.
Question 3: What is the priority nursing intervention for a client experiencing a tonic-clonic seizure?
A) Insert an oral airway
B) Protect the client from injury
C) Administer oxygen
D) Start an IV line
Correct Answer: B) Protect the client from injury
,Explanation: The primary goal during a seizure is to prevent physical injury by clearing the area of
harmful objects, supporting the head, and not restraining the client's movements.
Question 4: A client with heart failure is experiencing fluid overload. Which dietary instruction is
most important?
A) Increase protein intake
B) Limit sodium to 2-3 grams daily
C) Increase fluid intake
D) Avoid potassium-rich foods
Correct Answer: B) Limit sodium to 2-3 grams daily
Explanation: Sodium restriction helps reduce fluid retention and decreases the workload on the
heart by minimizing water retention and edema formation.
Question 5: Which manifestation indicates a client with spinal cord injury is experiencing autonomic
dysreflexia?
A) Bradycardia and hypotension
B) Severe throbbing headache and hypertension
C) Flaccid paralysis below the injury
D) Decreased bowel sounds
Correct Answer: B) Severe throbbing headache and hypertension
Explanation: Autonomic dysreflexia is a medical emergency characterized by severe hypertension,
pounding headache, bradycardia, and flushing above the level of injury due to uncontrolled
sympathetic response.
Question 6: For a client with diabetes mellitus, which complication causes the greatest long-term
risk?
A) Hypoglycemia
B) Diabetic ketoacidosis
C) Cardiovascular disease
D) Hyperosmolar hyperglycemic state
Correct Answer: C) Cardiovascular disease
,Explanation: Cardiovascular disease is the leading cause of death in diabetic patients due to
accelerated atherosclerosis, making it the most significant long-term complication.
Question 7: A client with hypothyroidism is prescribed levothyroxine. When should the nurse
instruct the client to take this medication?
A) With breakfast
B) At bedtime
C) On an empty stomach, 30-60 minutes before breakfast
D) With calcium supplements
Correct Answer: C) On an empty stomach, 30-60 minutes before breakfast
Explanation: Levothyroxine should be taken on an empty stomach to ensure optimal absorption, as
food, calcium, and iron can interfere with its absorption.
Question 8: Which nursing intervention is priority for a client with closed head injury?
A) Maintain adequate airway
B) Monitor intake and output
C) Provide pain medication
D) Encourage early ambulation
Correct Answer: A) Maintain adequate airway
Explanation: Maintaining a patent airway is the highest priority to prevent hypoxia, which can
worsen cerebral edema and increase intracranial pressure.
Question 9: A client with rheumatoid arthritis complains of morning stiffness lasting more than 1
hour. What is the best nursing intervention?
A) Encourage bed rest
B) Apply heat and promote gentle range-of-motion exercises
C) Administer pain medication only
D) Apply cold packs
Correct Answer: B) Apply heat and promote gentle range-of-motion exercises
Explanation: Heat application and gentle ROM exercises help reduce stiffness and maintain joint
function in rheumatoid arthritis, as morning stiffness is a hallmark symptom.
, Question 10: Which assessment finding would indicate worsening heart failure in a client previously
stable?
A) Weight loss of 2 pounds
B) Increased energy level
C) Sudden weight gain of 3 pounds in 2 days
D) Decreased appetite
Correct Answer: C) Sudden weight gain of 3 pounds in 2 days
Explanation: Sudden weight gain indicates fluid retention and worsening heart failure, as the heart
cannot effectively pump blood, leading to fluid accumulation.
Question 11: A client with type 2 diabetes has a blood pressure of 158/98 mmHg after lifestyle
modifications. What is the appropriate nursing action?
A) Continue monitoring every 6 months
B) Suggest more vigorous lifestyle changes
C) Inform client that medication may be required
D) Recommend stopping lifestyle modifications
Correct Answer: C) Inform client that medication may be required
Explanation: Blood pressure above 130/80 mmHg in diabetic patients requires medication
intervention despite lifestyle modifications, as diabetes increases cardiovascular risk.
Question 12: Which intervention is most helpful for a client with Alzheimer's disease?
A) Physical restraints
B) Communication strategies
C) Sedative medications
D) Isolation
Correct Answer: B) Communication strategies
Explanation: Communication strategies help maintain therapeutic relationships, reduce anxiety, and
support cognitive function in clients with dementia.
Question 13: A client with asthma is prescribed both a rescue inhaler (albuterol) and maintenance
medication (inhaled corticosteroid). What teaching is essential?
Scored A+ | Psychiatric Nursing Study Guide
Question 1: A client with osteoporosis is at highest risk for which complication?
A) Hypertension
B) Pathological fractures
C) Diabetes mellitus
D) Skin breakdown
Correct Answer: B) Pathological fractures
Explanation: Osteoporosis causes decreased bone density and structural deterioration of bone
tissue, leading to increased fragility and susceptibility to fractures, especially in the hip, spine, and
wrist.
Question 2: Which assessment finding would the nurse expect in a client with meningitis?
A) Flexion of hips and knees with passive neck flexion (positive Brudzinski's sign)
B) Hyperextension of the neck
C) Decreased deep tendon reflexes
D) Dilated pupils
Correct Answer: A) Flexion of hips and knees with passive neck flexion (positive Brudzinski's sign)
Explanation: Brudzinski's sign is a pathognomonic sign of meningitis where passive flexion of the
neck causes involuntary flexion of the hips and knees due to meningeal irritation.
Question 3: What is the priority nursing intervention for a client experiencing a tonic-clonic seizure?
A) Insert an oral airway
B) Protect the client from injury
C) Administer oxygen
D) Start an IV line
Correct Answer: B) Protect the client from injury
,Explanation: The primary goal during a seizure is to prevent physical injury by clearing the area of
harmful objects, supporting the head, and not restraining the client's movements.
Question 4: A client with heart failure is experiencing fluid overload. Which dietary instruction is
most important?
A) Increase protein intake
B) Limit sodium to 2-3 grams daily
C) Increase fluid intake
D) Avoid potassium-rich foods
Correct Answer: B) Limit sodium to 2-3 grams daily
Explanation: Sodium restriction helps reduce fluid retention and decreases the workload on the
heart by minimizing water retention and edema formation.
Question 5: Which manifestation indicates a client with spinal cord injury is experiencing autonomic
dysreflexia?
A) Bradycardia and hypotension
B) Severe throbbing headache and hypertension
C) Flaccid paralysis below the injury
D) Decreased bowel sounds
Correct Answer: B) Severe throbbing headache and hypertension
Explanation: Autonomic dysreflexia is a medical emergency characterized by severe hypertension,
pounding headache, bradycardia, and flushing above the level of injury due to uncontrolled
sympathetic response.
Question 6: For a client with diabetes mellitus, which complication causes the greatest long-term
risk?
A) Hypoglycemia
B) Diabetic ketoacidosis
C) Cardiovascular disease
D) Hyperosmolar hyperglycemic state
Correct Answer: C) Cardiovascular disease
,Explanation: Cardiovascular disease is the leading cause of death in diabetic patients due to
accelerated atherosclerosis, making it the most significant long-term complication.
Question 7: A client with hypothyroidism is prescribed levothyroxine. When should the nurse
instruct the client to take this medication?
A) With breakfast
B) At bedtime
C) On an empty stomach, 30-60 minutes before breakfast
D) With calcium supplements
Correct Answer: C) On an empty stomach, 30-60 minutes before breakfast
Explanation: Levothyroxine should be taken on an empty stomach to ensure optimal absorption, as
food, calcium, and iron can interfere with its absorption.
Question 8: Which nursing intervention is priority for a client with closed head injury?
A) Maintain adequate airway
B) Monitor intake and output
C) Provide pain medication
D) Encourage early ambulation
Correct Answer: A) Maintain adequate airway
Explanation: Maintaining a patent airway is the highest priority to prevent hypoxia, which can
worsen cerebral edema and increase intracranial pressure.
Question 9: A client with rheumatoid arthritis complains of morning stiffness lasting more than 1
hour. What is the best nursing intervention?
A) Encourage bed rest
B) Apply heat and promote gentle range-of-motion exercises
C) Administer pain medication only
D) Apply cold packs
Correct Answer: B) Apply heat and promote gentle range-of-motion exercises
Explanation: Heat application and gentle ROM exercises help reduce stiffness and maintain joint
function in rheumatoid arthritis, as morning stiffness is a hallmark symptom.
, Question 10: Which assessment finding would indicate worsening heart failure in a client previously
stable?
A) Weight loss of 2 pounds
B) Increased energy level
C) Sudden weight gain of 3 pounds in 2 days
D) Decreased appetite
Correct Answer: C) Sudden weight gain of 3 pounds in 2 days
Explanation: Sudden weight gain indicates fluid retention and worsening heart failure, as the heart
cannot effectively pump blood, leading to fluid accumulation.
Question 11: A client with type 2 diabetes has a blood pressure of 158/98 mmHg after lifestyle
modifications. What is the appropriate nursing action?
A) Continue monitoring every 6 months
B) Suggest more vigorous lifestyle changes
C) Inform client that medication may be required
D) Recommend stopping lifestyle modifications
Correct Answer: C) Inform client that medication may be required
Explanation: Blood pressure above 130/80 mmHg in diabetic patients requires medication
intervention despite lifestyle modifications, as diabetes increases cardiovascular risk.
Question 12: Which intervention is most helpful for a client with Alzheimer's disease?
A) Physical restraints
B) Communication strategies
C) Sedative medications
D) Isolation
Correct Answer: B) Communication strategies
Explanation: Communication strategies help maintain therapeutic relationships, reduce anxiety, and
support cognitive function in clients with dementia.
Question 13: A client with asthma is prescribed both a rescue inhaler (albuterol) and maintenance
medication (inhaled corticosteroid). What teaching is essential?
