GUIDE WITH ACTUAL EXAM QUESTIONS
AND CORRECT ANSWERS WITH DETAILED
RATIONALLES RATED A+
Two 20-year-old female clients on the psychiatric unit have
become very much attached to each other and are found in bed
together. They become angry and sarcastic when the nurse asks
one of them to return to her own bed. How can the nurse best
address this situation?
1. By asking the health care provider to transfer one of the clients
to another unit
2. By limiting their privileges for several days because their
behavior is undesirable
3. By adopting a matter-of-fact, nonjudgmental attitude and
setting limits on the behavior
4. By supervising them carefully and separating them when
possible throughout the day and always at night Correct Answer
3. By adopting a matter-of-fact, nonjudgmental attitude and
setting limits on the behavior
Everyone has the right to his or her sexual orientation and
preferences, but limits must be set on acting-out behavior on
,a psychiatric unit. Helping clients deal with their sexuality in
a more appropriate manner is more therapeutic than
continuous separation by the staff. Punishment is
inappropriate.
A client with newly diagnosed multiple myeloma asks, "How long
do you think I have to live?" What is the most appropriate
response by the nurse?
1. "Let me ask your primary healthcare provider for you."
2. "I can understand why you are worried."
3. "Tell me about your concerns right now."
4. "It depends on whether the tumor has spread." Correct Answer
3. "Tell me about your concerns right now."
The response "Tell me about your concerns right now"
encourages the client to review facts and provides an
opportunity to talk about feelings. The response "Let me ask
your primary healthcare provider for you" suggests the
nurse does not want to discuss the subject; it abdicates the
nurse's responsibility to explore the issue with the client.
Although it is an empathic answer, the response "I can
understand why you are worried" does not encourage the
client to explore feelings; it may increase anxiety. Although
the statement "It depends on whether the tumor has spread"
is true, the response does not encourage the client to
examine feelings.
,A client with cancer is told by a health care provider that the
cancer has metastasized to other organs and is untreatable. The
client tells the nurse, "I think they made a mistake. I don't think I
have cancer. I feel too good to be dying." Which stage of grief
does the nurse conclude that the client is experiencing?
1. Anger
2. Denial
3. Bargaining
4. Acceptance Correct Answer 2. Denial
The client has difficulty accepting the inevitability of death
and attempts to deny the reality of it. In the anger stage the
client strikes out with statements such as "Why me?" and
"How could God do this to me?" The client is angry at life
and is still angrier to be removed from it by death. In the
bargaining stage the client attempts to bargain for more time;
the reality of death is no longer denied, but the client tries to
manipulate and extend the remaining time. In the acceptance
stage the client accepts the inevitability of death and quietly
awaits it.
A client with schizophrenia is taking benztropine (Cogentin) in
conjunction with an antipsychotic. The client tells a nurse,
, "Sometimes I forget to take the Cogentin." What should the nurse
teach the client to do if this happens again?
1. Take 2 pills at the next regularly scheduled dose.
2. Notify the health care provider about the missed dose
immediately.
3. Take a dose as soon as possible, up to 2 hours before the next
dose.
4. Skip the dose, then take the next regularly scheduled dose 2
hours early. Correct Answer 3. Take a dose as soon as possible,
up to 2 hours before the next dose.
Taking a dose as soon as possible is the advised
intervention when a dose is missed; interruption of the
medication may precipitate signs of withdrawal such as
anxiety and tachycardia. Taking 2 pills at the next regularly
scheduled dose will provide an excessive amount of the
medication at one time. Notifying the health care provider
about the missed dose immediately is unnecessary. Skipping
a dose is not advised if the next regularly scheduled dose is
due within 2 hours.
A nurse encourages a client to join a self-help group after being
discharged from a mental health facility. What is the purpose of
having people work in a group?