NURS 420 Exam 3 Study Guide Questions With Complete
Solutions
A charge nurse is discussing manifestations of schizophrenia
with a newly licensed nurse. Which of the following
manifestations should the charge nurse identify as being
effectively treated by first-generation antipsychotics? (SATA)
Correct Answer - Auditory hallucinations
- Withdrawal from social situations
- Delusions of grandeur
- Severe agitation
A charge nurse is preparing a staff education session on
personality disorders. Which of the following personality
characteristics associated with all of the personality disorders
should the charge nurse include in the teaching (SATA)
Correct Answer - Difficulty in getting along with other
members of a group
- Display of defense mechanisms when routines are changed
- Difficulty understanding why it is inappropriate to have a
personal relationship with staff
A nurse caring for a client on an acute mental health unit. The
client reports hearing voices that are stating, "kill your doctor."
Which of the following actions should the nurse take first?
Correct Answer Initiate one-to-one observation of the client
A nurse in an acute care mental health facility is planning care
for a client who has dissociative fugue. Which of the following
interventions should the nurse add to the plan of care? Correct
Answer Work with the client on grounding techniques
,A nurse is assessing a client who is currently taking
perphenazine. Which of the following findings should the nurse
identify as an extrapyramidal symptoms (EPS)? (SATA)
Correct Answer - Drooling
- Involuntary arm movements
- Continual pacing
A nurse is assisting with a court-ordered evaluation of a client
who has antisocial personality disorder. Which of the following
findings should the nurse expect? (SATA) Correct Answer -
Attempts to convince other clients to relinquish their belongings
- Blames others for personal past and current problems
A nurse is caring for a client who has avoidant personality
disorder. Which of the following statements is expected from a
client who has this type of personality disorder? Correct
Answer "I'm scared that you're going to leave me"
A nurse is caring for a client who has borderline personality
disorder. The client says, "The nurse on the evening shift is
always nice. You are the meanest nurse ever!" The nurse should
recognize the client's statement as an example of which of the
following defense mechanisms? Correct Answer Splitting
A nurse is caring for a client who has bulimia nervosa and has
stopped purging behavior. The client tells the nurse about fears
of gaining weight. Which of the following responses should the
nurse make? Correct Answer "I understand you have concerns
about your weight, but first, let's talk about your recent
accomplishments."
,A nurse is caring for a client who has derealization disorder.
Which of the following findings should the nurse identify as an
indication of derealization? Correct Answer The client states
that the furniture in the room seems to be small and far away
A nurse is caring for a client who has schizoaffective disorder.
Which of the following statements indicates the client is
experiencing depersonalization? Correct Answer "I am no
one, and everyone is me."
A nurse is caring for a client who has schizophrenia and exhibits
a lack of grooming and a flat affect. The nurse should expect a
prescription for which of the following medications? Correct
Answer Risperidone
A nurse is caring for a client who has substance-induced
psychotic disorder and is experiencing auditory hallucinations.
The client states, "The voices won't leave me alone!" Which of
the following statements should the nurse make? (SATA)
Correct Answer - "When did you start hearing these things?"
- "It must be scary to hear voices."
- "Are the voices you hear telling you to hurt yourself?"
A nurse is caring for a client who takes ziprasidone. The client
reports difficulty swallowing the oral medication and becomes
extremely agitated with injectable administration. The nurse
should contact the provider to discuss a change to which of the
following medications? (SATA) Correct Answer - Olanzapine
- Aripiprazole
- Clozapine
, - Asenapine
A nurse is caring for an adolescent client who has anorexia
nervosa with recent rapid weight loss and a current weight of 90
lbs. Which of the following statements indicates the client is
experiencing the cognitive distortion of catastrophizing?
Correct Answer "Life isn't worth living if I gain weight."
A nurse is collecting an admission history for a client who has
acute stress disorder (ASD). Which of the following client
behaviors should the nurse expect? Correct Answer The client
expresses a sense of unreality about the traumatic incident
A nurse is completing an admission assessment for a client who
has schizophrenia. Which of the following findings should the
nurse document as positive symptoms? (SATA) Correct
Answer - Auditory hallucinations
- Use of clang associations
- Delusion of persecution
- Constantly waving arms
A nurse is involved in a serious and prolonged mass casualty
incident in the emergency department. Which of the following
strategies should the nurse use to help prevent developing a
trauma-related disorder? (Select all that apply)
A. Avoid thinking about the incident when it is over
B. Take breaks during the incident for food and water
C. Debrief with others following the incident
D. Hold emotions in check in the days following the incident
Solutions
A charge nurse is discussing manifestations of schizophrenia
with a newly licensed nurse. Which of the following
manifestations should the charge nurse identify as being
effectively treated by first-generation antipsychotics? (SATA)
Correct Answer - Auditory hallucinations
- Withdrawal from social situations
- Delusions of grandeur
- Severe agitation
A charge nurse is preparing a staff education session on
personality disorders. Which of the following personality
characteristics associated with all of the personality disorders
should the charge nurse include in the teaching (SATA)
Correct Answer - Difficulty in getting along with other
members of a group
- Display of defense mechanisms when routines are changed
- Difficulty understanding why it is inappropriate to have a
personal relationship with staff
A nurse caring for a client on an acute mental health unit. The
client reports hearing voices that are stating, "kill your doctor."
Which of the following actions should the nurse take first?
Correct Answer Initiate one-to-one observation of the client
A nurse in an acute care mental health facility is planning care
for a client who has dissociative fugue. Which of the following
interventions should the nurse add to the plan of care? Correct
Answer Work with the client on grounding techniques
,A nurse is assessing a client who is currently taking
perphenazine. Which of the following findings should the nurse
identify as an extrapyramidal symptoms (EPS)? (SATA)
Correct Answer - Drooling
- Involuntary arm movements
- Continual pacing
A nurse is assisting with a court-ordered evaluation of a client
who has antisocial personality disorder. Which of the following
findings should the nurse expect? (SATA) Correct Answer -
Attempts to convince other clients to relinquish their belongings
- Blames others for personal past and current problems
A nurse is caring for a client who has avoidant personality
disorder. Which of the following statements is expected from a
client who has this type of personality disorder? Correct
Answer "I'm scared that you're going to leave me"
A nurse is caring for a client who has borderline personality
disorder. The client says, "The nurse on the evening shift is
always nice. You are the meanest nurse ever!" The nurse should
recognize the client's statement as an example of which of the
following defense mechanisms? Correct Answer Splitting
A nurse is caring for a client who has bulimia nervosa and has
stopped purging behavior. The client tells the nurse about fears
of gaining weight. Which of the following responses should the
nurse make? Correct Answer "I understand you have concerns
about your weight, but first, let's talk about your recent
accomplishments."
,A nurse is caring for a client who has derealization disorder.
Which of the following findings should the nurse identify as an
indication of derealization? Correct Answer The client states
that the furniture in the room seems to be small and far away
A nurse is caring for a client who has schizoaffective disorder.
Which of the following statements indicates the client is
experiencing depersonalization? Correct Answer "I am no
one, and everyone is me."
A nurse is caring for a client who has schizophrenia and exhibits
a lack of grooming and a flat affect. The nurse should expect a
prescription for which of the following medications? Correct
Answer Risperidone
A nurse is caring for a client who has substance-induced
psychotic disorder and is experiencing auditory hallucinations.
The client states, "The voices won't leave me alone!" Which of
the following statements should the nurse make? (SATA)
Correct Answer - "When did you start hearing these things?"
- "It must be scary to hear voices."
- "Are the voices you hear telling you to hurt yourself?"
A nurse is caring for a client who takes ziprasidone. The client
reports difficulty swallowing the oral medication and becomes
extremely agitated with injectable administration. The nurse
should contact the provider to discuss a change to which of the
following medications? (SATA) Correct Answer - Olanzapine
- Aripiprazole
- Clozapine
, - Asenapine
A nurse is caring for an adolescent client who has anorexia
nervosa with recent rapid weight loss and a current weight of 90
lbs. Which of the following statements indicates the client is
experiencing the cognitive distortion of catastrophizing?
Correct Answer "Life isn't worth living if I gain weight."
A nurse is collecting an admission history for a client who has
acute stress disorder (ASD). Which of the following client
behaviors should the nurse expect? Correct Answer The client
expresses a sense of unreality about the traumatic incident
A nurse is completing an admission assessment for a client who
has schizophrenia. Which of the following findings should the
nurse document as positive symptoms? (SATA) Correct
Answer - Auditory hallucinations
- Use of clang associations
- Delusion of persecution
- Constantly waving arms
A nurse is involved in a serious and prolonged mass casualty
incident in the emergency department. Which of the following
strategies should the nurse use to help prevent developing a
trauma-related disorder? (Select all that apply)
A. Avoid thinking about the incident when it is over
B. Take breaks during the incident for food and water
C. Debrief with others following the incident
D. Hold emotions in check in the days following the incident
