lOMoARcPSD|42438002

Psychiatric mcqs 9 - practice mcqs

nursing ethics (Khyber Medical University)

Scan to open on Studocu

Studocu is not sponsored or endorsed by any college or university

Downloaded by Odhiambo Victor (odhiambovictor2424@[Link])
 lOMoARcPSD|42438002

1. Which nursing intervention is best for facilitating communication with a psychiatric client
who speaks a foreign language?

A. Rely on nonverbal communication.

B. Select symbolic pictures as aids.
C. Speak in universal phrases.
D. Use the services of an interpreter.
2. The nurse explains to a mental health care technician that a client’s obsessive-compulsive
behaviors are related to unconscious conflict between id impulses and the superego (or
conscience). On which of the following theories does the nurse base this statement?

A. Behavioral theory
B. Cognitive theory
C. Interpersonal theory
D. Psychoanalytic theory
3. The nurse observes a client pacing in the hall. Which statement by the nurse may help
the client recognize his anxiety?

A. “I guess you’re worried about something, aren’t you?

B. “Can I get you some medication to help calm you?”
C. “Have you been pacing for a long time?”
D. “I notice that you’re pacing. How are you feeling?”
4. A client with obsessive-compulsive disorder is hospitalized on an inpatient unit. Which
nursing response is most therapeutic?

A. Accepting the client’s obsessive-compulsive behaviors

B. Challenging the client’s obsessive-compulsive behaviors
C. Preventing the client’s obsessive-compulsive behaviors
D. Rejecting the client’s obsessive-compulsive behaviors
5. A 45-year-old woman with a history of depression tells a nurse in her doctor’s office that
she has difficulty with sexual arousal and is fearful that her husband will have an affair.
Which of the following factors would the nurse identify as least significant in contributing to
the client’s sexual difficulty?

A. Education and work history

B. Medication used
C. Physical health status
D. Quality of spousal relationship
6. Which nursing intervention is most appropriate for a client with anorexia nervosa during
initial hospitalization on a behavioral therapy unit?

A. Emphasize the importance of good nutrition to establish normal weight.

B. Ignore the client’s mealtime behavior and focus instead on issues of dependence and
independence.
C. Help establish a plan using privileges and restrictions based on compliance with
refeeding.
D. Teach the client information about the long-term physical consequence of anorexia.
7. A nurse is evaluating therapy with the family of a client with anorexia nervosa. Which of
the following would indicate that the therapy was successful?

A. The parents reinforce increased decision making by the client.

B. The parents clearly verbalize their expectations for the client.
C. The client verbalizes that family meals are now enjoyable.

Downloaded by Odhiambo Victor (odhiambovictor2424@[Link])

 lOMoARcPSD|42438002

D. The client tells her parents about feelings of low-self-esteem.

8. The nurse is working with a client with a somatoform disorder. Which client outcome goal
would the nurse most likely establish in this situation?

A. The client will recognize signs and symptoms of physical illness.

B. The client will cope with physical illness.
C. The client will take prescribed medications.
D. The client will express anxiety verbally rather than through physical symptoms.
9. Which method would a nurse use to determine a client’s potential risk for suicide?

A. Wait for the client to bring up the subject of suicide.

B. Observe the client’s behavior for cues of suicide ideation.
C. Question the client directly about suicidal thoughts.
D. Question the client about future plans.
10. A client with a bipolar disorder exhibits manic behavior. The nursing diagnosis is
Disturbed thought processes related to difficulty concentrating, secondary to flight of ideas.
Which of the following outcome criteria would indicate improvement in the client?

A. The client verbalizes feelings directly during treatment.

B. The client verbalizes positive “self” statement.
C. The client speaks in coherent sentences.
D. The client reports feelings calmer.
11. A client tells a nurse. “Everyone would be better off if I wasn’t alive.” Which nursing
diagnosis would be made based on this statement?

A. Disturbed thought processes

B. Ineffective coping
C. Risk for self-directed violence
D. Impaired social interaction
12. Which information is most essential in the initial teaching session for the family of a
young adult recently diagnosed with schizophrenia?

A. Symptoms of this disease imbalance in the brain.

B. Genetic history is an important factor related to the development of schizophrenia.
C. Schizophrenia is a serious disease affecting every aspect of a person’s functioning.
D. The distressing symptoms of this disorder can respond to treatment with
medications.
13. A nurse is working with a client who has schizophrenia, paranoid type. Which of the
following outcomes related to the client’s delusional perceptions would the nurse establish?

A. The client will demonstrate realistic interpretation of daily events in the unit.
B. The client will perform daily hygiene and grooming without assistance.
C. The client will take prescribed medications without difficulty.
D. The client will participate in unit activities.
14. A client with bipolar disorder, manic type, exhibits extreme excitement, delusional
thinking, and command hallucinations. Which of the following is the priority nursing
diagnosis?

A. Anxiety
B. Impaired social interaction
C. Disturbed sensory-perceptual alteration (auditory)
D. Risk for other-directed violence

Downloaded by Odhiambo Victor (odhiambovictor2424@[Link])

 lOMoARcPSD|42438002

15. A client who abuses alcohol and cocaine tells a nurse that he only uses substances
because of his stressful marriage and difficult job. Which defense mechanisms is this client
using?

A. Displacement
B. Projection
C. Rationalization
D. Sublimation
16. An 11-year-old child diagnosed with conduct disorder is admitted to the psychiatric unit
for treatment. Which of the following behaviors would the nurse assess?

A. Restlessness, short attention span, hyperactivity

B. Physical aggressiveness, low stress tolerance disregard for the rights of others
C. Deterioration in social functioning, excessive anxiety and worry, bizarre behavior
D. Sadness, poor appetite and sleeplessness, loss of interest in activities
17. The nurse understands that if a client continues to be dependent on heroin throughout
her pregnancy, her baby will be at high risk for:

A. Mental retardation.
B. Heroin dependence.
C. Addiction in adulthood.
D. Psychological disturbances.
18. The emergency department nurse is assigned to provide care for a victim of a sexual
assault. When following legal and agency guidelines, which intervention is most important?

A. Determine the assailant’s identity.

B. Preserve the client’s privacy.
C. Identify the extent of injury.
D. Ensure an unbroken chain of evidence.
19. Which factor is least important in the decision regarding whether a victim of family
violence can safely remain in the home?

A. The availability of appropriate community shelters

B. The nonabusing caretaker’s ability to intervene on the client’s behalf
C. The client’s possible response to relocation
D. The family’s socioeconomic status
20. The nurse would expect a client with early Alzheimer’s disease to have problems with:

A. Balancing a checkbook.
B. Self-care measures.
C. Relating to family members.
D. Remembering his own name
21. Which nursing intervention is most appropriate for a client with Alzheimer’s disease who
has frequent episodes emotional lability?

A. Attempt humor to alter the client mood.

B. Explore reasons for the client’s altered mood.
C. Reduce environmental stimuli to redirect the client’s attention.
D. Use logic to point out reality aspects.
22. Which neurotransmitter has been implicated in the development of Alzheimer’s disease?

A. Acetylcholine
B. Dopamine

Downloaded by Odhiambo Victor (odhiambovictor2424@[Link])

 lOMoARcPSD|42438002

C. Epinephrine
D. Serotonin
23. Which factors are most essential for the nurse to assess when providing crisis
intervention foe a client?

A. The client’s communication and coping skills

B. The client’s anxiety level and ability to express feelings
C. The client’s perception of the triggering event and availability of situational supports
D. The client’s use of reality testing and level of depression
24. The nurse considers a client’s response to crisis intervention successful if the client:

A. Changes coping skills and behavioral patterns.

B. Develops insight into reasons why the crisis occurred.
C. Learns to relate better to others.
D. Returns to his previous level of functioning.
25. Two nurses are co-leading group therapy for seven clients in the psychiatric unit. The
leaders observe that the group members are anxious and look to the leaders for answers.
Which phase of development is this group in?

A. Conflict resolution phase

B. Initiation phase
C. Working phase
D. Termination phase
26. Group members have worked very hard, and the nurse reminds them that termination is
approaching. Termination is considered successful if group members:

A. Decide to continue.
B. Elevate group progress
C. Focus on positive experience
D. Stop attending prior to termination.
27. The nurse is teaching a group of clients about the mood-stabilizing medications lithium
carbonate. Which medications should she instruct the clients to avoid because of the
increased risk of lithium toxicity?

A. Antacids
B. Antibiotics
C. Diuretics
D. Hypoglycemic agents
28. When providing family therapy, the nurse analyzes the functioning of healthy family
systems. Which situations would not increase stress on a healthy family system?

A. An adolescent’s going away to college

B. The birth of a child
C. The death of a grandparent
D. Parental disagreement
29. A client taking the monoamine oxidase inhibitor (MAOI) antidepressant isocarboxazid
(Marplan) is instructed by the nurse to avoid which foods and beverages?

A. Aged cheese and red wine

B. Milk and green, leaf vegetables
C. Carbonated beverages and tomato products
D. Lean red meats and fruit juices
30. Prior to administering chlorpromazine (Thorazine) to an agitated client, the nurse should:

Downloaded by Odhiambo Victor (odhiambovictor2424@[Link])

 lOMoARcPSD|42438002

A. Assess skin color and sclera

B. Assess the radial pulse
C. Take the client’s blood pressure
D. Ask the client to void
31. The nurse understands that electroconvulsive therapy is primary used in psychiatric care
for the treatment of:

A. Anxiety disorders.
B. Depression.
C. Mania.
D. Schizophrenia.
32. A client taking the MAOI phenelzine (Nardil) tells the nurse that he routinely takes all of
the medications listed below. Which medication would cause the nurse to express concern
and therefore initiate further teaching?

A. Acetaminophen (Tylenol)
B. Diphenhydramine (Benadryl)
C. Furosemide (Lasix)
D. Isosorbide dinitrate (Isordil)
33. The nurse is administering a psychotropic drug to an elderly client who has history of
benign prostatic hypertrophy. It is most important for the nurse to teach this client to:

A. Add fiber to his diet.

B. Exercise on a regular basis.
C. Report incomplete bladder emptying
D. Take the prescribed dose at bedtime.
34. The nurse correctly teaches a client taking the benzodiazepine oxazepam (Serax) to
avoid excessive intake of:

A. Cheese
B. Coffee
C. Sugar
D. Shellfish
35. The nurse provides a referral to Alcoholics Anonymous to a client who describes a 20-
year history of alcohol abuse. The primary function of this group is to:

A. Encourage the use of a 12-step program.

B. Help members maintain sobriety.
C. Provide fellowship among members.
D. Teach positive coping mechanisms.
36. Which client outcome is most appropriately achieved in a community approach setting in
psychiatric nursing?

A. The client performs activities of daily living and learns about crafts.
B. The client’s is able to prevent aggressive behavior and monitors his use of
medications.
C. The client demonstrates self-reliance and social adaptation.
D. The client experience experiences anxiety relief and learns about his symptoms.
37. A client with panic disorder experiences an acute attack while the nurse is completing an
admission assessment. List the following interventions according to their level of priority.

A. Remain with the client.

B. Encourage physical activity.

Downloaded by Odhiambo Victor (odhiambovictor2424@[Link])

 lOMoARcPSD|42438002

C. Encourage low, deep breathing.

D. Reduce external stimuli.
E. Teach coping measures.
38. The doctor has prescribed haloperidol (Haldol) 2.5 mg. I.M. for an agitated client. The
medication is labeled haloperidol 10 mg/2 ml. The nurse prepares the correct dose by
drawing up how many milliliters in the syringe?

A. 0.3
B. 0.4
C. 0.5
D. 0.6
39. The nurse enters the room of a client with a cognitive impairment disorder and asks
what day of the week it is: what the date, month, and year are; and where the client is. The
nurse is attempting to assess:

A. Confabulation
B. Delirium
C. Orientation
D. Perseveration
40. Which of the following will the nurse use when communicating with a client who has a
cognitive impairment?

A. Complete explanations with multiple details

B. Picture or gestures instead of words
C. Stimulating words and phrases to capture the client’s attention
D. Short words and simple sentences
41. A 75-year-old client has dementia of the Alzheimer’s type and confabulates. The nurse
understands that this client:

A. Denies confusion by being jovial.

B. Pretends to be someone else.
C. Rationalizes various behaviors.
D. Fills in memory gaps with fantasy.
42. An elderly client with Alzheimer’s disease becomes agitated and combative when a
nurse approaches to help with morning care. The most appropriate nursing intervention in
this situation would be to:

A. Tell the client family that it is time to get dressed.

B. Obtain assistance to restrain the client for safety.
C. Remain calm and talk quietly to the client.
D. Call the doctor and request an order for sedation.
43. In clients with a cognitive impairment disorder, the phenomenon of increased confusion
in the early evening hours is called:

A. Aphasia
B. Agnosia
C. Sundowning
D. Confabulation
44. Which of the following outcome criteria is appropriate for the client with dementia?

A. The client will return to an adequate level of self-functioning.

B. The client will learn new coping mechanisms to handle anxiety.
C. The client will seek out resources in the community for support.

Downloaded by Odhiambo Victor (odhiambovictor2424@[Link])

 lOMoARcPSD|42438002

D. The client will follow an establishing schedule for activities of daily living.
45. The school guidance counselor refers a family with an 8-year-old child to the mental
health clinic because of the child’s frequent fighting in school and truancy. Which of the
following data would be a priority to the nurse doing the initial family assessment?

A. The child’s performance in school

B. Family education and work history
C. The family’s perception of the current problem
D. The teacher’s attempts to solve the problem
46. The parents of a young man with schizophrenia express feelings of responsibility and
guilt for their son’s problems. How can the nurse best educate the family?

A. Acknowledge the parent’s responsibility.

B. Explain the biological nature of schizophrenia.
C. Refer the family to a support group
D. Teach the parents various ways they must change.
47. The nurse collecting family assessment data asks. “Who is in your family and where do
they live?” which of the following is the nurse attempting o identify?

A. Boundaries
B. Ethnicity
C. Relationships
D. Triangles
48. According to the family systems theory, which of the following best describes the
process of differentiation?

A. Cooperative action among members of the family

B. Development of autonomy within the family
C. Incongruent massages wherein the recipient is a victim
D. Maintenance of system continuity or equilibrium
49. The nurse is interacting with a family consisting of a mother, a father, and a hospitalized
adolescent who has a diagnosis of alcohol abuse. The nurse analyzes the situation and
agrees with the adolescent’s view about family rules. Which intervention is most
appropriate?

A. The nurse should align with the adolescent, who is the family scapegoat.
B. The nurse should encourage the parents to adopt more realistic rules.
C. The nurse should encourage the adolescent to comply with parental rules.
D. The nurse should remain objective and encourage mutual negotiation of issues.
50. A 16-year-old girl has retuned home following hospitalization for treatment of anorexia
nervosa. The parents tell the family nurse performing a home visit that their child has
always done everything to please them and they cannot understand her current
stubbornness about eating. The nurse analyzes the family situation and determines it is
characteristic of which relationship style?

A. Differentiation
B. Disengagement
C. Enmeshment
D. Scapegoating
Answers and Rationales

1. D. An interpreter will enable the nurse to better assess the client’s problems and
concerns. Nonverbal communication is important; however for the nurse to fully

Downloaded by Odhiambo Victor (odhiambovictor2424@[Link])

 lOMoARcPSD|42438002

determine the client’s problems and concerns, the assistance of an interpreter is

essential. The use of symbolic pictures and universal phrases may assist the nurse in
understanding the basic needs of the client; however these are insufficient to assess the
client with a psychiatric problem.
2. D. Psychoanalytic is based on Freud’s beliefs regarding the importance of
unconscious motivation for behavior and the role of the id and superego in opposition to
each other. Behavioral cognitive and interpersonal theories do not emphasize
unconscious conflicts as the basis for symptomatic behavior.
3. D. By acknowledging the observed behavior and asking the client to express his
feelings the nurse can best assist the client to become aware of his anxiety. In option A,
the nurse is offering an interpretation that may or may not be accurate; the nurse is
also asking a question that may be answered by a “yes” or “no” response, which is not
therapeutic. In option B, the nurse is intervening before accurately assessing the
problem. Option C, which also encourages a “yes” or “no” response, avoids focusing on
the client’s anxiety, which is the reason for his pacing.
4. A. A client with obsessive-compulsive behavior uses this behavior to decrease
anxiety. Accepting this behavior as the client’s attempt to feel secure is therapeutic.
When a specific treatment plan is developed, other nursing responses may also be
acceptable. The remaining answer choices will increase the client’s anxiety and
therefore are inappropriate.
5. A. Education and work history would have the least significance in relation to the
client’s sexual problem. Age, health status, physical attributes and relationship issues
have great influence on sexual expression.
6. C. Inpatient treatment of a client with anorexia usually focuses initially on
establishing a plan for refeeding to combat the effects of self-induced starvation.
Refeeding is accomplished through behavioral therapy, which uses a system of rewards
and reinforcements to assist in establishing weight restoration. Emphasizing nutrition
and teaching the client about the long-term physical consequences of anorexia maybe
appropriate at a later time in the treatment program. The nurse needs to assess the
client’s mealtime behavior continually to evaluate treatment effectiveness.
7. A. One of the core issues concerning the family of a client with anorexia is control.
The family’s acceptance of the client’s ability to make independent decisions is key to
successful family intervention. Although the remaining options may occur during the
process of therapy they would not necessarily indicate a successful outcome; the
central family issues of dependence and independence are not addressed in these
responses.
8. D. The client with a somatoform disorder displaces anxiety onto physical symptoms.
The ability to express anxiety verbally indicates a positive change toward improved
health. The remaining responses do not indicate any positive change toward increased
coping with anxiety.
9. C. Directly questioning a client about suicide is important to determine suicide risk.
The client may not bring up this subject for several reasons, including guilt regarding
suicide, wishing not to be discovered, and his lack of trust in staff. Behavioral cues are
important, but direct questioning is essential to determine suicide risk. Indirect
questions convey to the client that the nurse is not comfortable with the subject of
suicide and, therefore, the client may be reluctant to discuss the topic.
10. C. A client exhibiting flight of ideas typically has a continuous speech flow and jumps
from one topic to another. Speaking in coherent sentences is an indicator that the
client’s concentration has improved and his thoughts are no longer racing. The
remaining options do not relate directly to the stated nursing diagnosis.
11. C. The nurse should take any nurse statements indicating suicidal thoughts seriously
and further assess for other risk factors. The remaining diagnoses fail to address the
seriousness of the client’s statement.
12. D. This statement provides accurate information and an element of hope for the
family of a schizophrenic client. Although the remaining statements are true, they do

Downloaded by Odhiambo Victor (odhiambovictor2424@[Link])

 lOMoARcPSD|42438002

not provide the empathic response the family needs after just learning about the
diagnosis. These facts can become part of the ongoing teaching.
13. A. A client with schizophrenia, paranoid type, has distorted perceptions and views
people, institutions, and aspects of the environment as plotting against him. The
desired outcome for someone with delusional perceptions would be to have a realistic
interpretation of daily events. The client with a distorted perception of the environment
would not necessarily have impairments affecting hygiene and grooming skills. Although
taking medications and participating in unit activities may be appropriate outcomes for
nursing intervention, these responses are not related to client perceptions.
14. D. A client with these symptoms would have poor impulse control and would
therefore be prone to acting-out behavior that may be harmful to either himself or
others. All of the remaining nursing diagnoses may apply to the client with mania;
however, the priority diagnosis would be risk for violence.
15. C. Rationalization is the defense mechanism that involves offering excuses for
maladaptive behavior. The client is defending his substance abuse by providing reasons
related to life stressors. This is a common defense mechanism used by clients with
substance abuse problems. None of the remaining defense mechanisms involves
making excuses for behaviors.
16. B. Physical aggressiveness, low stress tolerance, and a disregard for the rights of
others are common behaviors in clients with conduct disorders. Restlessness, short
attention span, and hyperactivity are typical behaviors in a client with attention deficit
hyperactivity disorder. Deterioration in social functioning, excessive anxiety and worry
and bizarre behaviors are typical in schizophrenic disorders. Sadness, poor appetite,
sleeplessness, and loss of interest in activities are behaviors commonly seen in
depressive disorders.
17. B. Babies born to heroin-dependent women are also heroin-dependent and need to
go through withdrawal. There is no evidence to support any of the remaining answer
choices.
18. D. Establishing an unbroken chain of evidence is essential in order to ensure that the
prosecution of the perpetrator can occur. The nurse will also need to preserve the
client’s privacy and identify the extent of injury. However, it is essential that the nurse
follow legal and agency guidelines for preserving evidence. Identifying the assailant is
the job of law enforcement, not the nurse.
19. D. Socioeconomic status is not a reliable predictor of abuse in the home, so it would
be the least important consideration in deciding issues of safety for the victim of family
violence. The availability of appropriate community shelters and the ability of the
nonabusing caretaker to intervene on the client’s behalf are important factors when
making safety decisions. The client’s response to possible relocation (if the client is a
competent adult) would be the most important factor to consider; feelings of
empowerment and being treated as a competent person can help a client feel less like a
victim.
20. A. In the early stage of Alzheimer’s disease, complex tasks (such as balancing a
checkbook) would be the first cognitive deficit to occur. The loss of self-care ability,
problems with relating to family members, and difficulty remembering one’s own name
are all areas of cognitive decline that occur later in the disease process.
21. C. The client with Alzheimer’s disease can have frequent episode of labile mood,
which can best be handled by decreasing a stimulating environment and redirecting the
client’s attention. An over stimulating environment may cause the labile mood, which
will be difficult for the client to understand. The client with Alzheimer’s disease loses the
cognitive ability to respond to either humor or logic. The client lacks any insight into his
or her own behavior and therefore will be unaware of any causative factors.
22. A. A relative deficiency of acetylcholine is associated with this disorder. The drugs
used in the early stages of Alzheimer’s disease will act to increase available
acetylcholine in the brain. The remaining neurotransmitters have not been implicated in
Alzheimer’s disease.

Downloaded by Odhiambo Victor (odhiambovictor2424@[Link])

 lOMoARcPSD|42438002

10

23. C. The most important factors to determine in this situations are the client’s
perception of the crisis event and the availability of support (including family and
friends) to provide basic needs. Although the nurse should assess the other factors,
they are not as essential as determining why the client considers this a crisis and
whether he can meet his present needs.
24. D. Crisis intervention is based on the idea that a crisis is a disturbance in
homeostasis (steady state). The goal is to help the client return to a previous level of
equilibrium in functioning. The remaining answer choices are not considered the
primary outcome of crisis intervention, although they may occur as a side benefit.
25. B. Increased anxiety and uncertainly characterize the initiation phase in group
therapy. Group members are more self-reliant during the working and termination
phases.
26. A. As the group progresses into the working phase, group members assume more
responsibility for the group. The leader becomes more of a facilitator. Comments about
behavior in a group are indicators that the group is active and involved. The remaining
answer choices would indicate the group progress has not advanced to the working
phase.
27. C. The use of diuretics would cause sodium and water excretion, which would
increase the risk of lithium toxicity. Clients taking lithium carbonate should be taught to
increase their fluid intake and to maintain normal intake of sodium. Concurrent use of
any of the remaining medications will not increase the risk of lithium toxicity.
28. D. In a functional family, parents typically do not agree on all issues and problems.
Open discussion of thoughts and feeling is healthy, and parental disagreement should
not cause system stress. The remaining answer choices are life transitions that are
expected to increase family stress.
29. A. Aged cheese and red wines contain the substance tyramine which, when taken
with an MAOI, can precipitate a hypertensive crisis. The other foods and beverages do
not contain significant amounts of tyramine and, therefore, are not restricted.
30. C. Because chlorpromazine (Thorazine) can cause a significant hypotensive effect
(and possible client injury), the nurse must assess the client’s blood pressure (lying,
sitting, and standing) before administering this drug. If the client had taken the drug
previously, the nurse would also need to assess the skin color and sclera for signs of
jaundice, a possible drug side affect; however, based on the information given here,
there is no evidence that the client has received chlorpromazine before. Although the
drug can cause urine retention, asking the client to avoid will not alter this
anticholinergic effect.
31. B. The onset of action of the SSRI antidepressant paroxetine occurs around 3 to 4
weeks after drug therapy begins. Therefore, a client will seldom notice improvement
before this time. Continuing to take the drug is important for this client.
32. B. Over-the-counter medications used for allergies and cold symptoms are
contraindicated because they will increase the sympathomimetic effects of MAOIs,
possibly causing a hypertensive crisis. None of the remaining medications will increase
the sympathomimetic response and, therefore, are not contraindicated.
33. C. Urinary retention is a common anticholinergic side effect of psychotic medications,
and the client with benign prostatic hypertrophy would have increased risk for this
problem. Adding fiber to one’s diet and exercising regularly are measures to counteract
another anticholinergic effect, constipation. Depending on the specific medication and
how it is prescribed, taking the medication at night may or may not be important.
However, it would have nothing to do with urinary retention in this client.
34. B. Coffee contains caffeine, which has a stimulating effect on the central nervous
system that will counteract the effect of the antianxiety medication oxazepam. None of
the remaining foods is contraindicated.
35. B. The primary purpose of Alcoholics Anonymous is to help members achieve and
maintain sobriety. Although each of the remaining answer choices may be an outcome

Downloaded by Odhiambo Victor (odhiambovictor2424@[Link])

 lOMoARcPSD|42438002

11

of attendance at Alcoholics Anonymous, the primary purpose is directed toward sobriety

of members.
36. C. A therapeutic community is designed to help individuals assume responsibility for
themselves, to learn how to respect and communicate with others, and to interact in a
positive manner. The remaining answer choices may be outcomes of psychiatric
treatment, but the use of a therapeutic community approach is concerned with
promotion of self-reliance and cooperative adaptation to being with others.
37. ADCBE. The nurse should remain with the client to provide support and promote
safety. Reducing external stimuli, including dimming lights and avoiding crowded areas,
will help decrease anxiety. Encouraging the client to use slow, deep breathing will help
promote the body’s relaxation response, thereby interrupting stimulation from the
autonomic nervous system. Encouraging physical activity will help him to release
energy resulting from the heightened anxiety state; this should be done only after the
client has brought his breathing under control. Teaching coping measures will help the
client learn to handle anxiety; however, this can only be accomplished when the client’s
panic has dissipated and he is better able to focus.
38. C. Set up the problem as follows: 2.5mg/10mg = Xml/2ml X=0.5ml
39. C. The initial, most basic assessment of a client with cognitive impairment involves
determining his level of orientation (awareness of time, place, and person). The nurse
may also assess for confabulation and perseveration in a client with cognitive
impairment; but the questions in this situation would not elicit the symptom response.
Delirium is a type of cognitive impairment; however, other symptoms are necessary to
establish this diagnosis.
40. D. Short words and simple sentence minimize client confusion and enhance
communication. Complete explanations with multiple details and stimulating words and
phrases would increase confusion in a client with short attention span and difficulty with
comprehension. Although pictures and gestures may be helpful, they would not
substitute for verbal communication.
41. D. Confabulation is a communication device used by patients with dementia to
compensate for memory gaps. The remaining answer choices are incorrect.
42. C. Maintaining a calm approach when intervening with an agitated client is extremely
important. Telling the client firmly that it is time to get dressed may increase his
agitation, especially if the nurse touches him. Restraints are a last resort to ensure
client safety and are inappropriate in this situation. Sedation should be avoided, if
possible, because it will interfere with CNS functioning and may contribute to the
client’s confusion.
43. C. Sundowning is a common phenomenon that occurs after daylight hours in a client
with a cognitive impairment disorder. The other options are incorrect responses,
although all may be seen in this client.
44. D. Following established activity schedules is a realistic expectation for clients with
dementia. All of the remaining outcome statements require a higher level of cognitive
ability than can be realistically expected of clients with this disorder.
45. C. The family’s perception of the problem is essential because change in any one part
of a family system affects all other parts and the system as a whole. Each member of
the family has been affected by the current problems related to the school system and
the nurse would be interested in the data. The child’s performance in school and the
teacher’s attempts to solve the problem are relevant and may be assessed; however,
priority would be given to the family’s perception of the problem. The family education
and work history may be relevant, but are not a priority.
46. B. Te parents are feeling responsible and this inappropriate self-blame can be limited
by supplying them with the facts about the biologic basis of schizophrenia.
Acknowledging the patient’s responsibility is neither accurate nor helpful to the parents
and would only reinforce their feelings of guilt. Support groups are useful; however, the
nurse needs to handle the parents’ self-blame directly instead of making a referral for
this problem. Teaching the parents various ways to change would reinforce the parental

Downloaded by Odhiambo Victor (odhiambovictor2424@[Link])

 lOMoARcPSD|42438002

12

assumption of blame; although parents can learn about schizophrenia and what is
helpful and not helpful, the approach suggested in this option implies the parents’
behavior is at fault.
47. A. Family boundaries are parameters that define who is inside and outside the
system. The best method of obtaining this information is asking the family directly who
they consider to be members. The question asked by the nurse would not elicit
information about the family’s ethnicity or culture, nor does it address the nature of the
family relationship.
48. B. Differentiation is the process of becoming an individual developing autonomy while
staying in contact with the family system. Cooperative action among family members
does not refer to differentiation, although individuals who have a high level of
differentiation would be able to accomplish cooperative action. Incongruent messages
in which the recipient is a victim describe double-bind communication. Maintenance of
system continuity or equilibrium is homeostasis.
49. D. The nurse who wishes to be helpful to the entire family must remain neutral.
Taking sides in a conflict situation in a family will not encourage negotiation, which is
important for problem resolution. If the nurse aligned with the adolescent, then the
nurse would be blaming the parents for the child’s current problem; this would not help
the family’s situation. Learning to negotiate conflict is a function of a healthy family.
Encouraging the parents to adopt more realistic rules or the adolescent to comply with
parental rules does not give the family an opportunity to try to resolve problems on
their own.
50. C. Enmeshment is a fusion or overinvolvement among family members whereby the
expectation exists that all members think and act alike. The child who always acts to
please her parents is an example of how enmeshment affects development in many
cases, a child who develops anorexia nervosa exerts control only in the area of eating
behavior. The remaining options are not appropriate to the situation described.

Downloaded by Odhiambo Victor (odhiambovictor2424@[Link])