with ra onale) With complete solu on RATED A+
2025/2026
At the first mee ng of a group at a daycare center for older adults, the nurse asks one of the
members what kinds of things the client would like to do with the group. The older adult shrugs
and says, "You tell me. You're the leader." What would be the best response for the nurse to
make?
A."Yes, I am the leader today. Would you like to be the leader tomorrow?"
B."Yes, I will be leading this group. What would you like to accomplish?"
C."Yes, I have been assigned to lead this group. I will be here for the next 6 weeks."
D. "Yes, I am the leader. You seem angry about not being the leader yourself." - Correct
Answers ANS: B
Anxiety over par cipa on in a group and tes ng of the leader characteris cally occur in the
ini al phase of group dynamics. (B) provides informa on and refocuses the group to defining its
func on. (A) is manipula ve bargaining. (C) does not focus the group on its purpose or task. (D)
is interpre ng the client's feelings and is almost challenging.
A client who is being treated with lithium carbonate for manic depression begins to develop
diarrhea, vomi ng, and drowsiness. Which ac on should the nurse take?
A. No fy the health care provider immediately and force fluids.
B. Prior to giving the next dose, no fy the health care provider of these symptoms.
C. Record the symptoms and con nue with medica on as prescribed.
D. Hold the medica on and refuse to administer addi onal doses. - Correct Answers ANS: B
,Although these are expected symptoms, the health care provider should be no fied prior to the
next administra on of the drug (B). Early side effects of lithium carbonate (occurring with serum
lithium levels below 2 mEq/L) generally follow a progressive pa9ern, beginning with diarrhea,
vomi ng, drowsiness, and muscular weakness (C). At higher levels, ataxia, nnitus, blurred
vision, and large dilute urine output may occur. (A) will lower the lithium level. (D) is not
warranted.
A woman brings her 48-year-old husband to the outpa ent psychiatric unit and tells the nurse
that he has been sleepwalking, cannot remember who he is, and exhibits mul ple personali es.
These behaviors are o<en associated with which condi on?
A. Dissocia ve disorder
B. Obsessive-compulsive disorder
C. Panic disorder
D. Pos9rauma c stress syndrome - Correct Answers ANS: A
Sleepwalking, amnesia, and mul ple personali es are examples of detaching emo onal conflict
from one's consciousness (A). (B) is characterized by persistent, recurrent intrusive thoughts or
urges (obsessions) that are unwilled and cannot be ignored and provoke impulsive acts
(compulsions), such as constant and repeated hand washing. (C) is an acute a9ack of anxiety
characterized by personality disorganiza on. (D) is reexperiencing a psychologically terrifying or
distressing event that is outside the usual range of human experience such as war or rape.
During a home visit, a client with schizophrenia reports hearing voices that tell the client to
walk in the middle of the street. The nurse records several statements made by the client. Based
on which statement should the nurse determine that the client needs hospitaliza on?
A."Some mes I take an extra one of my pills when I hear the voices."
B."The voices are louder when I forget to take my medica on. "
C."No ma9er what I do, I cannot make the voices go away. "
, D."I just try to tell the voices to stop when they bother me. " - Correct Answers ANS: C
Hospitaliza on is needed if the client con nues to hear voices telling the client to do things that
can cause self-harm (C). (A or B) do not require hospitaliza on unless symptoms become severe.
The client should con nue symptom management strategies (D) to prevent hospitaliza on.
An adult client who lives in a residen al facility is mentally retarded and has a history of bipolar
disorder. During the past week, the client has refused to wear clothes and frequently exposes
their body to other residents. Which interven on should the nurse implement?
A. Establish a one-to-one rela onship to discuss the behavior.
B. Redirect the client to physically demanding ac vi es.
C. Encourage the client to verbalize thoughts when ac ng out.
D. Restrict social interac ons with other residents in the facility. - Correct Answers ANS: B
The client is exhibi ng manic behavior related to bipolar disorder, and the nurse should redirect
the client to ac vi es that are physically demanding (B) so that energy can be expended in a
socially acceptable manner. Psycho c clients are not capable of (A). When exhibi ng ac ng-out
behavior, the client is distracted and (C) is difficult. (D) is likely to increase manic behaviors, such
as mood swings and ac ng-out behaviors.
A client on the psychiatric unit seeks out a par cular nurse and imitates her mannerisms.
Which defense mechanism does the nurse recognize in this client?
A.Sublima on
B.Iden fica on
C.Introjec on
D.Repression - Correct Answers ANS: B