MENTAL HEALTH AND PSYCHIATRIC NURSING

DEFENSE MECHANISMS, CRISIS INTERVENTION AND ANXIETY RELATED DISORDERS

SITUATION: The term “defense mechanism” is used in two different ways. Both imply a sense of self protection,
with an organism engaging in a behavior with the goal of preventing harm, which may take the form of physical
harm or psychological harm. Defense mechanisms are widely used throughout the natural world and in human
society, and they take a wide range of forms.
1. A teenager gets mad at parents and begins staying out late at night. What type of defense mechanism is
demonstrated?
a. Projection
b. Dissociation
c. Acting out
d. Denial
ANSWER: C
Acting out is using actions rather than reflections or feelings during periods of emotional conflict. Projection is the
unconscious blaming of unacceptable inclinations or thoughts on an external object. Dissociation isdealing with
emotional conflict by a temporary alteration in consciousness or identity. Denial is the failure to acknowledge an
unbearable condition; failure to admit the reality of a situation, or how one enables the problem to continue
Reference: Sheila L. Videbeck. Psychiatric Mental health Nursing. 2nd edition. Page 51
2. A college student asks a teacher for help after receiving a bad grade on a test. Every suggestion the teacher
has is rejected by the student. What type of defense mechanism is demonstrated?
a. Displacement
b. Suppression
c. Rationalization
d. Help-rejecting complaining
ANSWER: D
Complaining or making repetitious requests for help that disguise covert feelings of hostility or reproach toward
others, which are then expressed by rejecting the suggestions, advice or help that others offer. Suppression is
the conscious exclusion of unacceptable thoughts and feelings from conscious awareness. Displacement is
ventilation of intense feelings toward persons less threatening than the one who aroused those feelings.
Rationalization is excusing own behavior to avoid guilt, responsibility, conflict, anxiety, or loss of self-respect.
Reference: Sheila L. Videbeck. Psychiatric Mental health Nursing. 2nd edition. Page 51
Reference:mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 145
3. A person makes a joke right after experiencing an embarrassing situation. What type of defense mechanism is
demonstrated?
a. Denial
b. Humor
c. Compensation
d. Reaction formation
ANSWER: B
Humor is emphasizing the amusing or ironic aspects of the conflict. Denial is failure to acknowledge an
unbearable condition; failure to admit the reality of a situation, or how one enables the problem to continue.
Compensation is overachievement in one area to offset real or perceived deficiencies in another area. Reaction
Formation is acting the opposite of what one thinks or feels.
Reference: Sheila L. Videbeck. Psychiatric Mental health Nursing. 2nd edition. Page 51
Reference:mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 145
4. An adult falls in love and fails to see the negative qualities of her partner. What type of defense mechanism is
demonstrated?
a. Repression
b. Substitution
c. Idealization
d. Sublimation
ANSWER: C
Idealization is attributing exaggerated positive qualities to others. Repression is excluding emotionally painful or
anxiety-provoking thoughts and feelings from conscious awareness. Substitution is replacing the desired
gratification with one that is more readily available. Sublimation is substituting a socially acceptable activity for
an impulse that is unacceptable
Reference: Sheila L. Videbeck. Psychiatric Mental health Nursing. 2nd edition. Pages 51-52
: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 145
5. The nurse should recognize that a patient who is unable to remember being raped by her brother when she
was 10 years old is using which of the following ego defense mechanisms?
a. Compensation
b. Regression
c. Repression
d. Undoing
ANSWER: C
This is an example of repression. It is defined as a defense mechanism which involves excluding emotionally
painful or anxiety provoking thoughts and feelings from conscious awareness.
Reference: Videbeck, S. L. (2004) Psychiatric Mental Health Nursing. 2nd edition. Lippincott Williams and Wilkins.
51
6. Upon returning home from work, a young man discovers that his mother has been in a serious automobile
accident. Initially, he responds to the news by stating, "No, I don't believe it. It can't be true." Which defense
mechanism is he using?
a. Introjection
b. Suppression
c. Denial
d. Repression
ANSWER: C
Denial is the avoidance of reality by ignoring or refusing to acknowledge unpleasant incidents. This defense
mechanism is used to allay anxiety immediately after a stressful event. Introjection is an intense form of
identification in which one incorporates the values or qualities of another person or group into one's own ego
structure. Suppression is the conscious analog of repression. A person intentionally uses suppression to
consciously exclude material from awareness. Repression is the unconscious exclusion of painful episodes from
awareness.
Reference: Videbeck, S. L. (2004) Psychiatric Mental Health Nursing. 2nd edition. Lippincott Williams and Wilkins.
51
7. A client diagnosed with cancer does not talk about or acknowledge her diagnonsis. Which of the following
defense mechanisms is this client using?
a. Denial
b. Identification
c. Projection
d. Rationalization
ANSWER: A
Failure to acknowledge the reality of the diagnosis is an example of the defense mechanism of denial.
Identification is a defense mechanism that occurs when a person avoids painful thoughts and emotions by
identifying with some symbolic sources of strength. Projection is a defense mechanism that occurs when people
avoid a negative evaluation of themselves by seeing their own unpleasant thoughts or actions in other people.
Rationalization (or making excuses) is a defense mechanism in which perceived controversial behaviors or
feelings are explained in a rational or logical manner to avoid the true explanation, to differentiate from the
original deterministic explanation, of the behavior or feeling in question.
Reference: Norman Keltner. Psychiatric Nursing 5ht edition Page 36-37
8. A man who was released from prison for selling narcotics has been rehabilitated and now works for a youth
drug prevention agency. His current behavior reflects which defense mechanism?
a. Denial
b. Displacement
c. Identification
d. Sublimation
ANSWER: D
Sublimation is a defense mechanism that Freud thought occurred when libidinal energy is channeled into socially
acceptable, approved activities. Identification is a defense mechanism that occurs when a person avoids painful
thoughts and emotions by identifying with some symbolic sources of strength. Failure to acknowledge the reality
of the diagnosis is an example of the defense mechanism of denial. Displacement is unconsciously discharging
pent-up feelings to a less threatening object
Reference: Norman Keltner. Psychiatric Nursing 5ht edition Page 36-37
SITUATION: When anxiety occurs, the mind first responds by an increase in problem-solving thinking, seeking
rational ways of escaping the situation. If this is not fruitful, a range of defense mechanisms may be triggered.
9. An angry man channels his hostilities into competitive sports in which there are many opportunities for
combat. The angry man’s actions characterize which of the following defense mechanisms?
a. Sublimation
b. Repression
c. Rationalization
d. Reaction formation
ANSWER: A
Sublimation is the unconscious rechanneling of intolerable or socially impulses or behaviors into activities that are
personally or socially acceptable. Repression is excluding emotionally painful or anxiety-provoking thoughts and
feelings from conscious
awareness. Rationalization is excusing own behavior to avoid guilt, responsibility, conflict, anxiety, or loss of selfrespect. Reaction
formation is acting the opposite of what one thinks or feels
Reference: Videbeck. Psychiatric Nursing. 2nd edition. Page 51
10. Mary, a client who attempted suicide recently, gave the following remarks to the nurse the next morning,
“Let’s not think about that now, maybe I’ll feel like thinking about it later.” The client is using which of the
following defense mechanisms?
a. Blocking
b. Denial
c. Suppression
d. Repression
ANSWER: C
By definition, this is the conscious, deliberate effort to avoid talking or thinking about painful, anxiety producing
experiences.
Repression is excluding emotionally painful or anxiety-provoking thoughts and feelings from conscious
awareness.
Reference: Videbeck. Psychiatric Nursing. 2nd edition. Page 51
11. A client in the psychiatric unit appears to imitate a certain nurse in the unit. The client seeks out for this
particular nurse and imitates her mannerisms. The nurse knows that the client is using which defense
mechanism?
a. Sublimation
b. Identification
c. Introjection
d. Repression.
Answer: B
Identification (B) is an attempt to be like someone or emulate the personality traits of another. (A) is substituting
an unacceptable feeling for one that is more socially acceptable. (C) is incorporating the values or qualities of an
admired person or group into one's own ego structure. (D) is the involuntary exclusion of painful thoughts or
memories from one's awareness.
Reference: Videbeck. Psychiatric Nursing. 2nd edition. Page 51
12. While assessing the defense mechanisms used by the client, the nurse recognizes the client’s use of defense
mechanisms as adaptive when the:
a. Mechanism used decreases anxiety.
c. Anxiety is expressed in behaviors.
b. Client seeks isolation to avoid stress.
d. Client can identify the stressor.
Answer: A
Rationale: The purpose of defense mechanisms is to reduce anxiety levels and allow the client to function
adequately. Seeking isolation to avoid stress (option B) is an unhealthy adaptive strategy. Anxiety is expressed in
behavior (option C); however, that behavior can be harmful to clients or others. Recognition of a stressor (option
D) is important but may not be useful in the client’s adaptive use of defense mechanisms.
13. A female client comes with the nurse for an evaluation with a therapist. As they sit down and prepare for the
interview, the client turns to the therapist, looks at him sternly and says, “I didn’t think you would even want to
see or talk to me.” The therapist responds, “How could this be since I do not even know who you are?” The nurse
understands that the client’s thinking is an example of which of the following defense mechanisms?
a. Denial
b. Projection
c. Reaction formation
d. Rationalization
Answer: B
Rationale: Projection is a process in which blame is attached to others or the environment for unacceptable
desires, thoughts, shortcomings, and mistakes. This client does not feel the therapist will care about her. Denial
(option A) is an attempt to screen or ignore unacceptable realities by refusing to acknowledge them. Reaction
formation (option C) is a mechanism that causes people to act exactly opposite to the way they feel.
Rationalization (option D) is the justification of certain behaviors by faulty logic and ascription of motives that are
socially acceptable but did not, in fact, inspire the behavior.
14. The nursing intervention for action-level defense mechanisms, such as conversion and regression, is to:
a. Teach the client to deal with impulses by taking constructive action.
b. Encourage the client to continue such defense mechanisms, as they are adaptive.
c. Listen to the client and encourage expression of feelings.
d. Orient client to reality and encourage participation in social activities.
Answer: A
Rationale: Conversion and regressive behavior impair the client’s ability to function in society. Teaching the client
constructive ways to cope would be helpful. These defense mechanisms are not adaptive and impair the client’s
function (option B). Listening to the client’s expression of feelings (option C) and orienting the client to reality
(option D) are therapeutic but will not assist the client in coping with maladaptive defense mechanisms and may
only increase the client’s anxiety level.
15. When talking to the nurse about his decision to drop out of school and marry his girlfriend who is pregnant, a
young college student says, “It’s really the best decision. It is important for a child to have two parents.” The
nurse recognizes that the client is using the defense mechanism known as:
a. Projection
b. Introspection
c. Displacement
d. Intellectualization
ANSWER: D
This is an example of intellectualization. It is the separation of the emotions of a painful event or situation from
the facts involved. There is an acknowledgment of the facts but not the emotions. Projection is unconscious
blaming of unacceptable inclinations on an external object. Displacement is the ventilation of intense feelings
toward a less threatening person than the one who aroused those feelings.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 51
16. A 7-year-old has been diagnosed as having acute myelogenous leukemia. The physician has discussed the
diagnosis with the parents and told them that their son has only a few months to live. While the parents are
sitting in the lounge after visiting their child, they both have a severe argument over something trivial. The nurse
should help them recognize that they are using the defense mechanism of:
a. Denial
b. Projection
c. Displacement
d. Compensation
ANSWER: C
This is an example of displacement. They were angry at the physician for the diagnosis and telling them that their
son has only a few months to live. There was a ventilation or transfer of intense feelings toward a person less
threatening than the person who aroused those feelings.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 51
17. A woman is brutally attacked and raped by her date following a party. She comes to the emergency
department for attention to her physical injuries. The nurse asks the client what happened to her and she replies
“I don’t know. I went to a party with my date and I don’t remember anything until I got home and my room mate
brought me here”. This is an example of which of the following defense mechanisms?
a. Rationalization
b. Reaction formation
c. Regression
d. Repression
ANSWER: D
The client is repressing the incident in order to avoid feelings of anxiety. Repression is the unconscious exclusion
of a painful thought, impulse or memory from awareness.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 51
SITUATION: Freud believed the self or ego used ego defense mechanisms, which are methods of attempting to
protect the self and cope with basic drives or emotionally painful thoughts, feelings, or events.
18. Mr. Delvalle, an account manager, loses an important advertising account and gets a flat tire while driving
home. That evening, he begins to find fault with everyone. Which defense mechanism is he using?
a. Displacement
b. Projection
c. Regression
d. Sublimation
ANSWER: A
This person is using displacement, a mechanism by which feelings of anger and rejection are discharged in an
indirect way that is perceived as safe (in this situation, by displacing anger related work and car problems onto
others). Projecting involves attributing one’s own emotions to or blaming them on others. Regression is a retreat
to an earlier level of developmental behavior in an attempt to relieve anxiety. Sublimation is the social acceptable
discharge or anger through such behavior as exercise or other productive activity.
Reference: Videbeck. S.L. Psychiatric Mental Health Nursing 3rd edition Page 51
19. Which term refers to the primary unconscious defense mechanism that blocks intense, anxiety-producing
situations from a person’s awareness?
a. Introjection
b. Regression
c. Repression
d. Denial
ANSWER: C
Repression, the unconscious exclusion from awareness of painful or conflicting thoughts, impulses, or memories,
is the primary ego defense. Other defense mechanisms tend to reinforce anxiety. Introjection is an intense
identification in which one incorporates values or qualities of another person or group into one’s own ego
structure. Regression is a retreat, during a time of stress, to an earlier level of developmental behavioral. Denial
is avoiding unpleasant realities by ignoring them.
Reference: Videbeck. S.L. Psychiatric Mental Health Nursing 3rd edition Page 51
20. A college student is outraged by the recent end of his long-term relationship. For his creative writing class, he
writes an essay on anger management. Which defense mechanism is he using?
a. Repression
b. Introjection
c. Undoing
d. Sublimation
ANSWER: D
Sublimation involves redirecting socially unacceptable behavior and needs into acceptable actions. This client is
exhibiting sublimation because he is redirecting his anger in an acceptable way. Repression is the unconscious
blocking out of unacceptable feelings or thoughts. Undoing involves attempting to “undo” harm a person feels he
may have done to another. Introjection is the process of absorbing the values or characteristics of another
person or group into one’s own ego.
Reference: Videbeck. S.L. Psychiatric Mental Health Nursing 3rd edition Page 51
21. A client becomes angry and belligerent toward the nurse after speaking on the phone with his mother. Nurse
Isabel recognizes this as what defense mechanism?
a. Rationalization
b. Repression
c. Displacement
d. Suppression
ANSWER: C
Displacement is a defense mechanism in which the client transfers his feelings for one person toward another
person who is less threatening. Rationalization is a defense mechanism in which the client makes excuses to
justify unacceptable feelings or behaviors. Repression is characterized an involuntary blocking of unpleasant
experiences form ones consciousness. Suppression is the conscious blocking of unpleasant experiences from
one’s awareness.
Reference: Videbeck. S.L. Psychiatric Mental Health Nursing 3rd edition Page 51
22. A female client is admitted to the emergency department after being sexually assaulted. Nurse Hannah notes
that the client is sitting calmly and quietly in the examination room and recognizes this behavior as a protective
defense mechanism. What defense mechanism is the client exhibiting?
a. Intellectualization
b. Denial
c. Regression
d. Displacement
ANSWER: B
Denial is a protectiveand adaptive reaction to increased anxiety. It involves consciously disowning intolerable
thoughts and impulses. This response is commonly seen in victims of sexual abuse. In intellectualization, the
client attempts to avoid expressing emotions associated with the stressful situation by using logic, analysis, and
reasoning. A client who uses regression reverts to an earlier developmental level in response to stress. With
displacement, the client transfers his feelings for one person toward another, less-threatening person.
Reference: Videbeck. S.L. Psychiatric Mental Health Nursing 3rd edition Page 51
23. Nurse Isabel is assessing a client who is talking about her son's recent death but who shows no emotion of
any kind. She recognizes this behavior as which of the following defense mechanisms?
a. Dissociation
b. Displacement
c. Intellectualization
d. Suppression
ANSWER: C
In intellectualization, the client attempts to avoid expressing emotions associated with the stressful situation by
using logic, analysis, and reasoning. Dissociation is dealing with emotional conflict by a temporary alteration in
consciousness or identity. With displacement, the client transfers his feelings for one person toward another,
less-threatening person. Suppression is conscious exclusion of unacceptable thoughts and feelings from conscious
awareness.
Reference: Videbeck. S.L. Psychiatric Mental Health Nursing 3rd edition Page 51
SITUATION: Adaptation and coping are a natural part of life. Crisis occurs when there is perceived challenge or
threat that overwhelms the capacity of the individual to cope effectively with the event. A crisis disrupts the life
of the individual experiencing the event.
24. The following except one are true about crisis:
a. Crisis is time limited
c. There is no such thing as chronic crisis
b. A crisis is same as psychiatric emergency
d. It can be an opportunity for growth
ANSWER: B
Crisis is regarded as time limited, lasting no more than 4-6 weeks. At the end of that time, the person in crisis
should have begun to come to grips with the consequences. By definition, there is no such thing as chronic crisis,
people who live in constant turmoil are not in crisis but in chaos. A crisis is not the same as a psychiatric
emergency that requires immediate attention. A person in crisis may not need an immediate intervention and
should not be viewed as having a mental disorder.
Crisis can be an opportunity for growth because new ways of coping are learned.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 803
25. A 13-year-old that has become increasingly withdrawn and uninterested in her schoolwork comes to the
clinic. Nurse Daniel notes that her behavior coincides with her pubertal changes. Which type of crisis is the girl
experiencing?
a. Adventitious crisis
b. Maturational crisis
c. Situational crisis
d. Natural crisis
ANSWER: B
Maturational crisis are normal part of growth and development, and that successfully resolving crisis at one stage
allows the child to move to the next. Puberty marks the transition from childhood to adolescence. Adventitious
crisis is initiated by unexpected, unusual events that can affect an individual or a multitude of people disasters
(man made and natural). Situational crisis occurs in response to sudden, unexpected events in individual’s life.
Natural is not a clinical type of crisis.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 804
26. Which approach by the nurse is best when responding to a client in crisis?
a. Behavioral approach
b. Nondirective approach
c. Problem-solving approach
ANSWER: C

d. Supportive approach
Crisis intervention employs a systematic, problem solving approach in attempting to help clients deal with crisis.
A behavioral approach or a nondirective approach would not be used. Although a supportive approach is part of
crisis intervention, the overall method guiding the nurse is the problem-solving approach.
Reference: Ann Isaac. Psychiatric Nursing. 4th edition. Page 228.
27. Crisis is described as self-limiting; that is, the crisis does not last indefinitely but usually exists for:
a. 2 weeks
b. 4-6 weeks
6 months
d. one year
ANSWER: B
Crisis usually exists for 4-6 weeks.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 61
28. A 60-year-old client complains of headaches, restlessness, and insomnia. During an interview, the nurse
learns that the symptoms began 3 months ago after the client was forced into early retirement. The nurse
recognizes that the client is probably experiencing:
a. A social crisis
b. A situational crisis
c. An adventitious crisis
d. A developmental crisis
ANSWER: B
This is an example of a situational crisis. Other examples are loss of a job, physical or emotional illness of self or
a family member.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 61
29. A patient is admitted to the emergency room following a sexual assault. Which of the following statements
should the nurse recognize as most pertinent whether or not an individual experiences a crisis?
a. The patient’s behavior prior to the assault
c. The patient’s perception of the event
b. The patient’s past history
d. The patient’s understanding of STD’s
ANSWER: C
Crisis is a turning point in an individual’s life that produces and overwhelming emotional response. Individuals
experience a crisis when they confront some life circumstance or a stressor that they cannot effectively manage
through the use of their customary coping skills. Donna Aguilera identified three important factors that influence
whether or not an individual experiences a crisis.
The individual’s perception of the event
The availability of emotional support
Availability of adequate coping mechanisms
Reference: Videbeck, S. L. (2004) Psychiatric Mental Health Nursing. 2nd edition. Lippincott Williams and Wilkins.
61
30. A recently engaged 22-year-old woman loses her fiancé in a drunken driving accident. She complains of
difficulty eating, sleeping, and working. Her reaction is considered:
a. a pathologic response to grief.
c. a noncrisis situation.
b. a crisis caused by traumatic stress.
d. a crisis of anticipated life transitions.
ANSWER: B
The scenario presents an individual in crisis. A traumatic event can create symptoms, such as difficulty eating,
sleeping, and working. Individuals in crisis can experience psychological pain that isn't classified as pathologic.
The sudden accident isn't an anticipated event.
Reference: Videbeck, S. L. (2004) Psychiatric Mental Health Nursing. 2nd edition. Lippincott Williams and Wilkins.
61
31. A client doesn't make eye contact with the nurse during an interview. The nurse suspects that the client's
behavior has a cultural basis. What should the nurse do first?
a. Read several articles about the client's culture.
b. Ask staff members of a similar culture about the client's behavior.
c. Observe how the client and the client's family and friends interact with one another and with other staff
members.
d. Accept the client's behavior because it's probably culturally-based.
ANSWER: C
Assessing the client's interactions with others helps to determine whether the behavior is part of a usual pattern.
It also may help the nurse understand the meaning of the behavior for this particular client. Reading about a
different culture, consulting other staff members, and talking with the client are helpful after the nurse has
observed the client's interaction with others. The nurse must be able to accept the client as an individual but
need not accept unhealthy or inappropriate behaviors. The nurse should work with the client to better understand
the cultural differences.
32. The school nurse receives a referral from .a teacher about a sudden behavior change in a 13-year-old. girl
who has become increasingly withdrawn and uninterested in her schoolwork. Upon interviewing the girl'and her
teacher, the nurse notes that the girl's behavioral changes correspond with a rapid onset of puberty. Which type
of crisis is the girl experiencing?
a. Adventitious crisis
b. Developmental crisis
c. Situational crisis
d. Natural crisis
ANSWER: B
A developmental crisis is one that occurs in response to a particular transition from one stage of maturation to
another in the life cycle. Puberty marks the transition from childhood to adolescence. An adventitious crisis
occurs in response to severe trauma or disaster. A situational crisis occurs in response to sudden, unexpected
events in an individual's life. Puberty is neither sudden nor unexpected; it is a normal transition. A natural crisis
is not a clinical type of crisis.
Reference: Norman Keltner. Psychitric Nursing 5th edition Page
33. The nurse is intervening with a client who experienced a crisis following the sudden death of a loved one.
Which of the following actions should the nurse take after establishing initial rapport?
a. Ask the client to describe his social support system
b. Call the client's family to discuss the problem
c. Encourage the client to describe in detail what happened
d. Refer the client to a bereavement support group
ANSWER: C
It is important for the nurse to assess the client's perception of the overwhelming problem and the events
preceding the crisis situation because these are the factors that define the crisis. Determining the social support
system is important; however, this assessment would follow the client's description of the problem (the first step
in crisis intervention). Calling the family to discuss the problem or referring the client to a bereavement support
group may or may not be appropriate, depending on the client's perception of the problem; but, again, these
would occur later in the intervention.
Reference: Norman Keltner. Psychitric Nursing 5th edition Page
34. The nurse is teaching an assigned client the problem solving approach as an adaptive coping strategy for
dealing with stress. To evaluate the success of the teaching, the nurse asks the client what step should be taken
after assessing facts, formulating goals and choosing alternative choices. Which of the following answers is
correct and indicates the client understands the nurse's instruction?
a. Choose an alternative from among the choices.
c. Determine risks and behaviors of each alternative.
b. Decide which alternative is the correct one.
d. Ask for opinions from significant others.
ANSWER: C
Problem solving has an 8-point decision making model. The step that comes after assessing facts, formulating
goals, and choosing alternative choice is determining the risks and benefits of each alternative. Selecting an
alternative would come later in the model. The client tests each alternative and evaluates the outcome until the
appropriate alternative is found. No step calls for asking others' opinions.
Reference: Brown. Mental Health Nursing Care. 2nd edition
35. The nurse will most likely evaluate that a client, in the hospital, has made progress toward resolving the
nursing diagnosis of Ineffective Coping if the client has done which of the following things?
a. Convinced the treatment team to discharge him
b. Frequently asked for the nurse's guidance and suggestions
c. Identified and discussed behaviors that are maladaptive
d. Attend one hundred percent of all classes assigned
ANSWER: C
Part of the resolution of the problem of Ineffective Coping is the client's ability to identify and discuss behaviors
that are maladaptive. Once the client recognizes these, s/he can begin to work on adaptive means to cope.
Attending classes does not constitute actual learning. Frequently asking others for guidance and suggestions
demonstrates a dependency on staff rather than self-reliance. Convincing the treatment team to discharge the
client could be manipulative behavior which is maladaptive.
Reference: Brown. Mental Health Nursing Care. 2nd edition
36. A client who is unable to cope with the sudden loss of a job and who is feeling confused and unable to make
decisions is said to be experiencing which of the following?
a. Adventitious crisis
b. Maturational crisis
c. Situational crisis
d. Social crisis
Answer: C
Rationale: A situational crisis is one that is often sudden and unavoidable. The stressful event threatens a
person’s physical, emotional, or social integrity. An adventitious crisis (option A) occurs from an accidental or
sporadic event. A maturational crisis (option B) occurs because of a situation occurring from the maturing
process, such as in adolescents or older adults. A social crisis (option D) is a crisis that occurs within a social
context.
37. In assessing a client in crisis, it is important for the nurse to first assist the client to identify:
a. The client’s feelings.
c. Others who might be affected by the event.
b. The realistic nature of the event.
d. An immediate action plan.
Answer: A
Rationale: It is helpful for the client to identify the feelings he or she has about the crisis in order to feel validated
and begin work on the problem. The realistic nature of the event (option B), others impacted by the event (option
C), and a plan of action (option D) all are important next steps once the client has identified his or her own
feelings.
38. A client was admitted to the hospital with suicidal ideations and a plan to harm himself. His wife recently
died after a very brief illness, and he sees no reason to go on living. He says that his wife was his best friend,
and they did everything together. He feels alone in the world and yet allows no one into his life. Which of the
following nursing diagnoses best categorizes this problem?
a. Helplessness related to the death of his wife
b. Ineffective individual coping related to loneliness
c. Post-trauma response related to suicidal plan
d. Social isolation related to the loss of his wife and failure to establish meaningful relationships
Answer: D
Rationale: In order to deal with crisis, clients must identify and be able to rely on others in their world whom they
find supportive and who will be there after the immediate crisis is over. There is not enough data to support the
other nursing diagnoses (options A, B, and C).
39. A client came into the crisis center for assistance after he was involved in clean-up efforts following a
shooting at a local high school. The client says he has been feeling very anxious since his involvement in these
efforts. The nurse working with the client chooses which of the following to help him cope with the experience?
a. Arrange for his priest to visit with him.
b. Advise him to avoid going near the school for at least 90 days.
c. Send him to the Emergency Department for further evaluation because he is experiencing a crisis situation,
which is an emergency.
d. Create an opportunity for to him to talk about his experience, ask him about how he has coped thus far, and
explore enhanced coping skills.
Answer: D
Rationale: Assessing current coping and assisting in the enhancement of coping skills will enable the client to gain
problem solving in his present circumstance and afford new coping for the future. Arranging for a priest (option
A) may be an effective intervention, but the nurse must first assess whether the client would find this
intervention beneficial. Avoiding the school for 90 days (option B) may or may not be either effective or possible
and referring the client to Emergency Department (option C) is too early at this time.
40. When working with the client in crisis, which of the following is most important?
a. Obtaining complete assessment of the client’s past history
b. Remaining focused on the immediate problem
c. Determining whether the client may have had a part in the emergence of the crisis
d. Assisting the client to identify what is similar about this crisis to other crises in the client’s life
Answer: B
Rationale: The nurse must remain focused on the immediate problem as there is not enough time and no need to
delve into the complete past history (option A). The client’s role in the current crisis (option C) is not relevant at
this time, although it may be more important in learning to prevent future crisis situations. Assisting the client to
identify what is similar about this crisis to other crises (option D) may be a usual next step.
SITUATION: 25-year-old patient, Mr. Makipot reported to the clinic complaining uneasiness and occasionally
breathlessness. He mentioned that his anxiety attacks had been gradually increasing and in worst cases, he
would get severe nausea that would get better after inducing vomiting. He reported that his anxiety was caused
mainly by some office work pressure thus resulting to incomplete paper works; some social situations would also
trigger the nausea at times. He tried playing a sport to control his anxiety and same thing happened it also
triggered anxiety and caused nausea; hence he avoided playing sports.
41. Based on the assessment, Nurse Pimpito identified Mr. Makipot’s anxiety is at what level?
a. Mild
b. Moderate
c. Severe
d. Panic
ANSWER: C
Severe anxiety causes reduction in perceptual field, person cannot complete tasks, cannot solve problems or
learn effectively behavior geared toward anxiety relief and usually ineffective, doesn’t respond to redirection,
feels awe, dread, or horror. Physiologic responses: Severe headache, nausea, vomiting, and diarrhea, Trembling,
Rigid stance, Vertigo, Pale, Tachycardia, Chest pain. Mild anxiety is a positive state of heightened awareness and
sharpened senses, allowing the person to learn new behaviors and solve problems. The person can take in all
available stimuli (perceptual field). Moderate anxiety involves a decreased perceptual field (focus on immediate
task only); the person can learn new behavior or solve problems only with assistance. Another person can
redirect the person to the task.
Reference: Sheila L. Videbeck. Psychiatric Mental health Nursing. 2nd edition. Page 271
42. The following nursing interventions are appropriate for a client with acute anxiety except:
a. Place the client in safe and quiet place
c. Approach the client in calm manner
b. Encourage the client to verbalize concerns
d. Touch the client to comfort him
ANSWER: D
Nurse must establish rapport and trust with the anxious client before using therapeutic touch. Touching an
anxious client may actually increase anxiety. Trust can be established by approaching the client in a calm and
confident manner; providing a place that is quiet, safe, and private; and encouraging the client to verbalize
feelings and concerns.
Reference: Sheila L. Videbeck. Psychiatric Mental health Nursing. 2nd edition. Page 113
43. The client is at moderate level of anxiety, the following are appropriate nursing actions except:
a. The nurse must be certain that the client is following what the nurse is saying
b. Speaking in short, simple, and easy-to-understand sentences
c. Redirecting the client back to the topic.
d. Providing health teaching to client
ANSWER: D
Client with moderate anxiety has selective inattention, thus providing teaching at this level is ineffective. Health
teaching is effective for client with mild anxiety. Other options are correct actions for client with moderate level of
anxiety.
Reference: Sheila L. Videbeck. Psychiatric Mental health Nursing. 2nd edition. Page 271
44. A client is admitted to the unit visibly anxious. When assessing the client, the nurse would expect to see
which cardiovascular effect produced by the sympathetic nervous system?
a. Syncope
b. Decreased blood pressure
c. Increased heart rate
d. Decreased pulse rate
ANSWER: C
Sympathetic cardiovascular responses to stress include increased heart rate, cardiac contractility, and cardiac
output; increased blood pressure; and peripheral vasoconstriction. Syncope is a response to parasympathetic
stimulation
Reference:mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 393
45. A client comes to the emergency department while experiencing a panic attack. The nurse can best respond
to a client having a panic attack by:
a. Staying with the client until the attack subsides.
b. Telling the client everything is under control.
c. Telling the client to lie down and rest.
d. Talking continually to the client by explaining what is happening.
ANSWER: A
The nurse should remain with the client until the attack subsides. If the client is left alone he may become more
anxious. Giving false reassurance is inappropriate in this situation. The client should be allowed to move around
and pace to help expend energy. The client may be so overwhelmed that he can't follow lengthy explanations or
instructions, so the nurse should use short phrases and slowly give one direction at a time.
Reference: Sheila L. Videbeck. Psychiatric Mental health Nursing. 2nd edition. Page 272
46. According to the DSM-IV-TR, anxiety is considered excessive when it:
a. Occurs more than once a day
b. Is present more days than not for a period of 6 months or more
c. Causes the person to change his or her plans one or more times per week
d. Results in a person staying at home
ANSWER: B
According to the DSM-IV-TR, anxiety is considered excessive when it is present more days than not for a period
of 6 months or more. Anxiety over this long period of time will begin to interfere with the individual’s ability to
function appropriately.
Reference: Kneisl. Contemporary Psychiatric Mental Health Nursing 2nd edition
47. Which of the following communication techniques is most effective to use with a severely anxious client?
a. Ask open-ended questions to facilitate self-expression.
b. Provide an open, populated area to decrease fears of abandonment.
c. Speak slightly louder than usual to improve communication.
d. Stand or sit in the center of the client's visual field to facilitate attention.
ANSWER: D
When anxiety becomes severe, the client no longer can pay attention or take in information. The nurse’s goal
must be to lower the person’s anxiety level to moderate or mild before proceeding with anything else. It is also
essential to remain with the person, because anxiety is likely to worsen if he or she is left alone. Talking to the
client in a low, calm, and soothing voice can help. If the person cannot sit still, walking with him or her while
talking can be effective.
What the nurse talks about matters less than how he or she says the words. Helping the person to take deep,
even breaths can help lower anxiety.
Reference: Sheila L. Videbeck. Psychiatric Mental health Nursing. 4nd edition.
48. While conducting morning rounds, Nurse Hannah is interrupted by a client hospitalized with severe anxiety.
The client states, “I’m so upset. I feel like I am falling apart and nobody seems to care.” Which one of the
following responses is most therapeutic?
a. “Why do you think that nobody cares about you?”
b. “You are not really falling apart, you are just having an anxiety attack”
c. “Try to regain control of your feelings by thinking of a positive goal”
d. “I can see you that you are upset, I will talk with you as soon as I finish my rounds”
ANSWER: D
Option D shows that the nurse recognizes and respects the client’s feelings. Option A is incorrect because it can
cause the client to become defensive. Option B is incorrect because it intellectualizes the client’s feelings. Option
C is incorrect because it does not allow the client to vent feelings of frustration.
SITUATION: Mr. X is admitted in the unit for an acute anxiety reaction.
49. The nurse approaches Mr. X who is mute, sitting rigidly in his chair, immobile and staring at a fixed point.
Given these behaviors, the client is said to be in which level of anxiety?
a. Mild
b. Moderate
c. Severe
d. Panic
ANSWER: D
A panic level of anxiety may be manifested by purposeless behaviour, distorted perceptual fields and
unintelligible communication. Some persons in a panic state may be immobile and unable to initiate actions.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 270
50. The long-term goal, “The client will learn new ways of coping with anxiety,” is most appropriate at which level
of anxiety?
a. Mild
b. Moderate
c. Severe
d. Panic
ANSWER: B
Long-term goals for moderate anxiety should focus on assisting the client to understand the causes of anxiety
and learn new coping strategies. These goals cannot be accomplished when the anxiety level is high because the
client cannot focus on learning at this anxiety level.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 270
51. Mr. X is prescribed buspirone (BuSpar). Teaching instructions for newly prescribed buspirone should include
which of the following?
a. A warning that immediate sedation can occur with a resultant drop in pulse
b. A reminder of the need to schedule blood work in 1 week to check blood levels of the drug
c. A warning about the incidence of neuroleptic malignant syndrome (NMS)
d. Instruct the client to rise slowly from a sitting position and warn about the drug's delayed therapeutic effect,
which occurs in 14 to 30 days
ANSWER: D
The client should be informed that the drug's therapeutic effect might not be reached for 14 to 30 days (2-4
weeks). The client must be instructed to continue taking the drug as directed. Blood level checks aren't
necessary. NMS hasn't been reported with this drug, but tachycardia is frequently reported.
Nursing management: Instruct client to rise slowly from sitting position (causes orthostatic hypotension), take
the drug with food, report persistent euphoria, restlessness and agitation
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 272
Reference: Springhouse Nurse’s Drug Guide. (2005) 6th edition. Lippincott Williams and Wilkins
52. The following are anxiolytic drugs which are classified as benzodiazepines, except:
a. Diazepam (Valium)
b. Alprazolam (Xanax)
c. Clonazepam (Klonopin)
d. Buspirone (Buspar)
ANSWER: D
Buspirone is a non-benzodiazepine anxiolytic drug. Option a, b and c are benzodiazepines.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 272
Reference: Springhouse Nurse’s Drug Guide. (2005) 6th edition. Lippincott Williams and Wilkins
53. Benzodiazepines or barbiturates were used as sleeping pills in the past. They are commonly prescribed for
sleep and anxiety. Which drug is prescribed for a benzodiazepine overdose?
a. Naloxone
b. Regetidine
c. Flumazenil
d. Valium
ANSWER: C
Flumazenil (Romazicon) has been used as an antidote in the treatment of benzodiazepine overdoses. It reverses
the effects of benzodiazepines by competitive inhibition at the benzodiazepine binding site on the GABA receptor.
Class: Benzodiazepine antagonist
Therapeutic effect: Awakens patients from the sedative effects of benzodiazepines
NLE Question, December 2008
Reference: Springhouse Nurses Drug Guide 2005. 6th edition. Lippincott Williams and Wilkins.
SITUATION: In dealing with psychiatric patients, the nursing process can present unique challenges. Emotional
problems may be vague, not visible like many physiological disruptions. Emotional problems can also show
different symptoms and arise from a number of causes. Similarly, past events may lead to very different form of
present behaviors. Many psychiatric patients are unable to describe their problems. They may be highly
withdrawn, highly anxious, or out of touch with reality. Their ability to participate in the problem solving process
may also be limited if they see themselves as powerless. Nursing process aims at individualized care to the
patient and the care is adapted to patient’s unique needs.
54. Which of the nursing diagnoses is appropriate for the nurse to make for a client with binge disorder?
a. Ineffective thermoregulation
c. Ineffective health maintenance
b. Risk for self mutilation
d. Anxiety
ANSWER: D
An appropriate nursing diagnosis for a client with binge disorder is anxiety. A client with binge disorder behavior
feels a great deal of distress over the binge behavior. Ineffective thermoregulation and risk for health
maintenance are nursing diagnosis appropriate for bulimia.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 521
55. Upon client’s admission for psychiatric hospitalization, the nurse documents the following: Client refuses to
bathe or dress, remains in room most of the day, and speaks infrequently to peers or staff. Which nursing
diagnosis would be the priority at this time?
a. Anxiety
b. Decisional conflict
c. Self care deficit
d. Social isolation
ANSWER: D
These behaviors indicate the client’s withdrawal from others and possible fear or mistrust of relationship. There is
no indication of Anxiety or Decisional Conflict in the information provided. Although the client refuses to bathe or
dress, Self care deficit would not be the priority nursing diagnosis in this situation.
Reference: Ann Isaac. Psychiatric Nursing. 4th edition. Page 131
SITUATION: Anxiety disorders are the most common of the psychiatric illnesses treated by health care
providers. Anxiety disorders affect individuals of all ages.
56. A client has been experiencing irritability, difficulty concentrating, difficulty sleeping, and withdrawal for the
past 8 weeks since the house burned to the ground after an explosion. The nurse assesses that this client is
experiencing?
a. Depression
b. A panic attack
c. Post traumatic stress disorder
d. Generalized anxiety disorder
ANSWER: C
Clients may experience clinical manifestations of PTSD after experiencing a traumatic event, such as a house
burning down. Clinical manifestations need to be present for at least 1 month for a diagnosis of PTSD. The client’s
clinical manifestations begin abruptly after a traumatic event and last for a period greater than a month.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 428-429
57. A client reports experiencing nightmares and constant worry about the weather since typhoon Ondoy
destroyed the client’s house. The nurse assesses that this client is experiencing:
a. Hallucinations
b. Panic attacks
c. Flashbacks
d. Delusions
ANSWER: C
A client who repeatedly experiences nightmares and constantly worries about the weather since a typhoon
destroyed his house is experiencing flashbacks. Clients who have flashbacks have recurrent intrusive recollections
of the traumatic event. Clients with delusions, hallucinations, and panic attacks would reexperience the
traumatic event.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 428-429
58. A client with generalized anxiety disorder reports feeling of increasingly ineffective at work and at home
states, “I’m letting everyone down. I do not know what to do anymore”. Which of the following diagnoses should
the nurse select as most appropriate?
a. Disturbed thought process
c. Impaired adjustment
b. Decisional conflict
d. Ineffective role performance
ANSWER: D
A client who has a GAD expresses difficulty in performing usual roles in work and family environments. There is
no evidence that the client’s thinking is not reality based. There is no particular decision with which client is
wrestling. There is no indication that the client is facing any change in circumstances.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 423-424
SITUATION: Somatization is a concept used in nursing because it focuses on the individual’s experience and
expression of unexplained symptoms. This notion acknowledges and respects the individual’s expression of
unexplained symptoms.
59. The following statements describe somatoform disorders:
a. Physical symptoms are explained by organic causes
c. Expression of conflicts through bodily symptoms
b. It is a voluntary expression of psychological conflicts
d. Management entails a specific medical treatment
ANSWER: C
Somatoform disorder is one in which the patient experiences and expresses suffering through their reported
physical signs and symptoms. Option A: Manifestations do not have an organic basis. Option B. This occurs
unconsciously. Option D: Medical treatment is not used because the disorder does not have a structural or
organic basis.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 482
60. A 30-year-old male employee frequently complains of low back pain that leads to frequent absences from
work. Consultation and tests reveal negative results. The client has which somatoform disorder?
a. Somatization Disorder
b. Hypochondriaisis
c. Conversion Disorder
d. Somatoform Pain Disorder
ANSWER: D
This is characterized by severe and prolonged pain that causes significant distress. Option A: This is a chronic
syndrome of somatic symptoms that cannot be explained medically and is associated with psychosocial distress.
Option B: This is an unrealistic preoccupation with a fear of having a serious illness. Option C: Characterized by
alteration or loss in sensory or motor function resulting from a psychological conflict.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 497
61. What would be the best response to the client’s repeated complaints of pain?
a. “I know the feeling is real tests revealed negative results.”
b. “I think you’re exaggerating things a little bit.”
c. “Try to forget this feeling and have activities to take it off your mind”
d. “So tell me more about the pain”
ANSWER: A
The most difficult aspect of nursing care is developing a sound, positive nurse-patient relationship, yet this
relationship is crucial. Without it the nurse is just one more provider who fails to meet the patient’s expectations.
Option B” This is a demeaning statement. Option C: This belittles the client’s feelings. Option D: Giving undue
attention to the physical symptom reinforces the complaint.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 491
SITUATION: Dissociative disorders are thought to be responses to extreme external or internal events or
stressors. The onset of these disorders may be sudden or occur gradually and the course of each day may be
long term or transient.
62. The nurse assess a client suspected of having a dissociative disorder. Which of the following describes
dissociative disorder?
a. Are produced by anxiety
c. Are fixed and chronic
b. Appear only in schizophreania
d. Are voluntary
ANSWER: A
Dissociative disorders are produced by extreme anxiety, when circumstances become overwhelming and the
traditional coping mechanism cannot contain the anxiety. Dissociative disorders are not confined to schizophrenia
but are a diagnostic category by itself. Dissociative disorders are not fixed and chronic but change and can be
temporary. Dissociative disorders are not voluntary.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 429
63. According to Sullivan, dissociation is:
a. An anecdote for hopelessness
c. Withdrawing from other people
b. An anxiety-reducing mechanism
d. A way to escape extreme boredom
ANSWER: B
Sullivan viewed dissociation as an anxiety-reducing mechanism that functions by restricting awareness. According
to Sullivan, if an individual is required to use dissociation excessively, their ability to make meaningful
connections between the event and their thoughts and feelings about the event becomes limited.
Reference: Firsch. Psychiatric Mental Health Nursing 4th edition
64. Which of the following client’s history is most likely to contribute to the diagnosis of dissociative disorder?
a. Brain tumor
b. Substance abuse
c. Child abuse
d. Seizures
ANSWER: C
Traumatic events are often precipitating factors in dissociative disorders because they result in the individual’s
attempt to protect the self from remembering traumatic events. Brain tumor, substance abuse, and epilepsy have
not been established as positive links to dissociative disorder.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 491
Reference: Ann Isaac. Psychiatric Nursing. 4th edition. Page 52
65. A client is amnestic for periods of time. During other periods of time, the client reports feeling “as if someone
else is in control of me.” This presentation most closely describes:
a. Fugue
b. Amnesia
c. Dissociative identity disorder
d. Depersonalization
ANSWER: C
Dissociative identity disorder (DID) refers to individuals who possess two or more distinct identities, at least two
of which periodically take control of the individual’s behavior--typically not at the same time. Periods of amnesia
are found in DID and may be quite extensive. The expression of multiple identities (personalities) may be
exceedingly dramatic and even colorful. Each identity may have a separate name, gender, voice, or set of
psychological symptoms.
Reference: Firsch. Psychiatric Mental Health Nursing 4th edition
66. A client failed to show up for work for 2 weeks and is found wandering at a campsite several hundred miles
away from home. The client is confused about his identity. This presentation MOST closely describes:
a. Fugue
b. Amnesia
c. Dissociative identity disorder
d. Depersonalization
ANSWER: A
An individual experiencing a dissociative fugue state may experience periods of prolonged wandering. In many
situations the challenge is to identify that an individual is actually in a fugue state since these persons may
function remarkably normally until detailed questioning reveals that they do not know who they are or why they
are in a particular place. Dissociative fugue is believed to be the unconscious avoidance of a particular place and
unknowingly traveling to a different place.
Reference: Firsch. Psychiatric Mental Health Nursing 4th edition
67. A client describes reacting to a stressful event by “feeling as if I was watching myself in a dream.” This MOST
closely describes:
a. Fugue
b. Amnesia
c. Dissociative identity disorder
d. Depersonalization
ANSWER: D
Depersonalization occurs when a person feels as if he or she is living in a dream or even a film. The person may
feel as if he or she is watching him- or herself from a vantage point outside the body.
Reference: Firsch. Psychiatric Mental Health Nursing 4th edition
68. The major difference between dissociative amnesia and dissociative fugue is that in dissociative fugue there
is:
a. Localized amnesia.
c. A period where the person wanders.
b. Memory for the time during the fugue state.
d. Systemized amnesia.
Answer: C
During a fugue, there is a period where the person wanders. There is no memory for the time during the fugue
state. Localized amnesia or systemized amnesia may occur in dissociative amnesia but not in a dissociative
fugue.
Reference: Firsch. Psychiatric Mental Health Nursing 4th edition
69. Freud identified a number of defense mechanisms. It is evident that the nurse recognizes one of these
common defense mechanisms for a client with dissociative identity disorder when the nurse charts that the client
has used:
a. Denial.
b. Rationalization.
c. Fixation.
d. Repression.
Answer: D
Repression explains the loss of conscious awareness in dissociation. Fixation is not completing developmental
tasks in earlier stages of development. Rationalization is making excuses. Denial is lack of acknowledging.
Reference: Firsch. Psychiatric Mental Health Nursing 4th edition
70. Which of the following nursing interventions is important for a client with dissociative identity disorder (DID)?
a. Give antipsychotic medications as prescribed.
b. Maintain consistency when interacting with the client.
c. Confront the client about the use of alter personalities.
d. Prevent the client from interacting with others when one of the alter personalities is in control.
ANSWER: B
Establishing trust and support is important when interacting with a client with DID. Many of these clients have
had few healthy relationships.
Option A – medications hasn’t proven effective in the treatment of DID.
Option C – confronting the client about the alter personalities would be ineffective because the client has little, if
any, knowledge of the presence of these other personalities.
Option D – isolating the client wouldn’t be therapeutically beneficial.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 212-213
SITUATION: Anya, a 32-year-old single female was wheelchair-bound. She had been placed in 47 different
foster homes between the ages of 12 and 19 and had been sexually abused throughout her childhood and
adolescence by male foster parents. A psychiatrist who had hypnotized her diagnosed that she has four additional
personalities: Diana, four years old, sought security and attention and had temper tantrums; Gail, age 12, had a
personality similar to the patient's as a teenager; John, age 26, appeared as an auditory hallucination disturbing
her sleep, which reactivated her memories of sexual abuse; the Deathman, age 27, intervened when John, Gail
and Diana argued. The patient would become suicidal after receiving orders to die from the Deathman or from
John. However, Gail and Diana would then provide sufficient support to allow her to get help either from the
police or from psychiatric services.
71. The nurse identifies which of the following as primary feature of dissociative identity disorder?
a. The presence of alternating control by two or more personalities
b. The personalities are always unaware of each other
c. The condition is unique to schizophrenia
d. All the personalities possess similar sexual, racial and intellectual characteristics
ANSWER: A
The presence of multiple personalities is a classic feature of DID. The personalities are sometimes aware of each
other but often out of the awareness of the primary personality. DID is a condition in a diagnostic category by
itself and is not necessarily tied to schizophrenia. The personalities may possess different sexual, racial, and
intellectual characteristics
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 858
72. The nurse understands which of the following as a known manifestation of dissociative identity disorder?
a. The personalities are all aware of one another
c. The recall of traumatic events is intact
b. The disorder is never chronic
d. The client was confronted with an intolerable terror event
ANSWER: D
The initial event of a dissociative disorder was an event the client confronted and found so intolerable that the
client’s memory split off into another personality. The personalities are often out of the awareness of the primary
personality. The disorder can be episodic or chronic. Recall of the traumatic event is not available to the primary
personality.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 858
73. The nurse is caring for a client who has dissociative disorder. Which of the following would indicate to the
nurse that the client is deteriorating?
a. Expressions of suicide and hopelessness
c. The presence of substance abuse
b. Expressions of forgetfulness
d. The inability to take care of basic needs
ANSWER: A
Expressions of suicidal ideation and feelings of hopelessness and worthlessness are critical markers for impending
suicide attempts in a client who has dissociative disorder. They indicate that the client’s condition is deteriorating
and that intervention is essential. Forgetfulness is not itself a dangerous risk. Substance abuse may preclude the
diagnosis of a dissociative disorder. The client with dissociative disorder maintains the ability to conduct activities
of daily living.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 858
SITUATION: Ms. M is a 60-year-old widowed Chinese woman with a 6-month history of episodic chest tightness,
shortness of breath, pain that moves all over her body, and numbness in her legs. During an attack, pain travels
from her chest to her abdomen, groin, and legs. The pain is often accompanied by a sensation of intermittent
“hotQi” (air) coming from her abdomen to her throat, making her believe that she is being choked. She also
describes the feeling as if she is in a closed room or small space. Ms. M is anxious and frustrated about her
symptoms and thinks she might have a serious medical problem. She has had frequent medical evaluations by
her primary care physician and second opinions from various specialists. Ms. M consulted a doctor of traditional
Chinese medicine and tried some herbal medications, but has had no relief. She has refused to see a psychiatrist.
74. The psychiatrist made a diagnosis of panic disorder and recommended a treatment regimen involving an
antidepressant agent and benzodiazepine. Which of the following client’s assessments on the use of
benzodiazepine would be a priority concern for the nurse?
a. History of alcohol abuse
c. A lack of adequate coping skills
b. A history of closed head injury
d. A diet high in tyramine-rich foods
ANSWER: A
Because benzodiazepines have serious abuse potential, they are generally contraindicated for clients with a
history of alcohol or substance abuse. A lack of adequate coping skills, a closed head injury, and a diet high in
tyramine-rich foods are not factors in prescribing benzodiazepines.
Reference: Amy Karch: Focus on Nursing Pharmacology. 3rd edition. Page 295
75. A client who has been regularly taking lorazepam (Ativan) for the past three months suddenly reports onset
of tremors, irritability and insomnia
hours after quitting Ativan. The nurse documents this client’s
manifestations as an indication of which of the following?
a. Withdrawal
b. Delirium Tremens
c. Toxicity
d. conversion disorder
ANSWER: A
Withdrawal symptoms include tremors, irritability, and insomnia. These are the classic features of withdrawal
from benzodiazepines. Lorazepam (Ativan) is a benzodiazepine used in treatment of anxiety.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 403
76. What should be included in the plan of care for a client who is at the panic level of anxiety?
a. Offer warm blanket and darken the room
b. Ask the client to describe how she usually copes with her anxiety
c. Stay with the client
d. Calling the security to alert the situation
ANSWER: C
Staying with the client is the priority.
During panic level anxiety, the person’s safety is the primary concern. He or she cannot perceive potential harm
and may have no capacity for rational thought. The nurse must keep talking to the person in a comforting
manner, even though the client cannot process what the nurse is saying. Going to a small, quiet, and nonstimulating environment
may help to reduce anxiety. The nurse can reassure the person that this is anxiety, that
it will pass, and that he or she is in a safe place. The nurse should remain with the client until the panic recedes.
Reference: Videbeck. Psychiatric Nursing. 2nd edition. Page 272
SITUATION: In generalized anxiety disorder, a person has frequent or nearly constant, nagging feelings of
worry or anxiety. These feelings are either unusually intense or out of proportion to the real troubles and dangers
of the person's everyday life.
The disorder is defined as persistent worry every day or almost every day for six months or more. In some cases,
a person with generalized anxiety disorder feels he or she has always been a worrier, even since childhood or
adolescence. In other cases, the anxiety may be triggered by a crisis or a period of stress, such as a job loss, a
family illness or the death of a relative.
77. A client diagnosed with generalized anxiety disorder reports feeling of increasing ineffectiveness at work and
at home. The client states, “I’m letting everyone down, I do not know what to do anymore.” Which of the
following diagnosis should the nurse select as most appropriate for this client?
a. Disturbed thought process
b. Decisional conflict
c. Impaired adjustment
d. Ineffective role performance
ANSWER: D
A client who has generalized anxiety disorder expresses difficulty in performing usual role in work and family
environments. There is no evidence that the client’s thinking is not reality based. There is no particular decision
with which client is wrestling. There is no indication is facing any change in circumstances.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 424
78. A client being assessed for anxiety disorder relates to the nurse a concern that displays many physical clinical
manifestations. The client states, “My heart races, my chest gets tight, and I can’t breathe. I must be having a
heart attack.” Which of the following is the nurse’s most appropriate response?
a. “Those manifestations, although frightening, are very common with anxiety”
b. “Has anyone in your family had a heart attack?”
c. “I will ask the doctor to run some tests, may be you have a heart condition”
d. “I also experience that when I get too anxious”
ANSWER: A
Accurate information about the physical manifestations of anxiety can be reassuring. Telling the client that the
clinical manifestations are frightening and common in anxiety not only reassures the client but lets the client
know the etiology of the clinical manifestations. Asking a client if anyone in the family has had a heart attack will
likely increase the anxiety and will not help address the client’s main concern. Telling a client that the doctor
should run some tests only reinforces the concern with the physical manifestations. It is inappropriate to self
disclose and will not likely comfort the client.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 393
79. Nurse Glo is reviewing the care plan for a client with generalized anxiety disorder. Which of the following is
an appropriate goal? The client will:
a. Describe traumatic event in detail
c. Be able to confront the phobic stimulus if accompanied
b. Report no dissociative episodes
d. Report tolerating the presence of mild anxiety during activities
ANSWER D
It is unrealistic for clients with GAD to be anxiety free. Being able to tolerate mild anxiety so the client can
perform activities is a realistic goal. Describing a traumatic event, reporting no dissociative episodes, or
confronting a phobic stimulus are not goals for a GAD.
Reference: Norman Keltner. Psychiatric nursing. 5th edition. Page 415
80. A provider most often bases the prescription of a cyclic antidepressant medication for a specific client on
which of the following?
a. The cost per dose coupled with the anticipated length of treatment
b. The amount of sedation, anxiety reduction, or psychostimulation desired
c. To which pharmaceutical advertisements the client has recently been exposed
d. Color and size of the tablets or capsules and ease of swallowing
ANSWER: B
Providers base the prescription of a cyclic antidepressant on the amount of sedation, anxiety reduction, or
psychostimulation desired. Concern must also be given to choosing medication in an effort to minimize side
effects. The provider normally starts with a low initial dosage prescription. Over a period of 1 to 4 weeks, the
dosage is increased gradually, until there is clinical improvement for the client.
Reference: Cavan Frisch. Psychiatric Mental Health Nursing 4th edition
81. Nurse Ela-eheh is reviewing the care plan for a client with generalized anxiety disorder. Which of the
following is an appropriate goal? The client will:
a. Describe traumatic event in detail
c. Be able to confront the phobic stimulus if accompanied
b. Report no dissociative episodes
d. Report tolerating the presence of mild anxiety during activities
ANSWER D
It is unrealistic for clients with GAD to be anxiety free. Being able to tolerate mild anxiety so the client can
perform activities is a realistic goal. Describing a traumatic event, reporting no dissociative episodes, or
confronting a phobic stimulus are not goals for a GAD.
Reference: Norman Keltner. Psychiatric nursing. 5th edition. Page 415
82. Nurse Mary is assessing an obviously anxious client. Nurse Mary should use which of the following
approaches?
a. Don’t mention the anxiety unless the client does
b. Teach the client some relaxation techniques
c. Avoid any questioning about the anxiety until it has subsided
d. Ask specific, direct questions about the anxiety
ANSWER: D
Specific direct questions will help the client become aware of the anxiety and give pertinent information about it.
Not questioning the client until anxiety has subsided or not mentioning the anxiety unless the client avoids
assessing the client’s anxiety, which must be done for the assessment to proceed. Teaching a client a relaxation
exercises is an intervention without adequate assessment and premature.
Reference: Norman Keltner. Psychiatric nursing. 5th edition. Page 415
83. A client tells Nurse Gardo that he stopped taking the buspirone (Buspar) for his generalized anxiety disorder
because it doesn’t seem to work after taking it for a week. Which of the following explanations should Nurse
Gardo provide the client?
a. Buspirone is not for anxiety disorder
c. It takes 2-3 weeks to take effect
b. Probably the dosage is low
d. Buspirone must be taken on an empty stomach
ANSWER: C
The full effect of buspirone (Buspar) takes at least 2 to 3 weeks to become apparent. Buspar is routinely used for
chronic anxiety. The adequacy of the dose cannot be assessed until after the drug has been taken for at least 2
to 3 weeks. There is no evidence that food or the absence of food has any effect on absorption
Reference: Norman Keltner. Psychiatric nursing. 5th edition. Page 273,415
SITUATION: A war veteran is admitted in the psychiatric unit with a diagnosis of post-traumatic stress disorder
(PTSD).
84. Which of the following structures have been found in recent studies to most likely play a role in exaggerated
stress response found in various anxiety disorders such as post-traumatic stress disorder (PTSD)?
a. Brainstem
b. Frontal lobe
c. Hippocampus and amygdale
d. Hypothalamus and thalamus
ANSWER: C
Recent studies indicate that dysregulation of the hippocampus and amygdala may play a role in exaggerated
stress responses found in various anxiety disorders such as post-traumatic stress disorder (PTSD). The amygdala
is involved in short-term memory and its conversion to long-term memory. It is involved with the hippocampus in
encoding emotional memories like those experienced during a traumatic event.
Reference: Cavan Frisch. Psychiatric Mental Health Nursing 4th edition
85. Nurse Hannah is completing the assessment. Which findings would be expected by Nurse Hannah to be
reported by this client?
1. Excessive sleeping
3. Fitful sleep
5. Terrifying nightmares
2. Hair pulling
4. Fear of returning to sleep
a. 1 and 2
b. 3, 4, and 5
c. All except 2
d. All of the above
ANSWER: B
Sleep loss (fitful sleep), not excessive sleeping, is a physical symptom characteristic of PTSD. Hair pulling is an
anxiety symptom, but not a symptom of PTSD.
Reference: Cavan Frisch. Psychiatric Mental Health Nursing 4th edition
SITUATION: Ms. J is a 37-year-old woman who presents to the emergency department with abdominal pain.
She reports that she has suffered from chronic pain since her adolescence. She has a history of multiple
abdominal surgeries, the most recent was for pain felt due to adhesions. These operations have failed to reduce
her complaints of pain. Her physical examination, vital signs, and laboratory examination, including CBC,
urinalysis, and chemistry profile, are within normal limits. She is referred back to her primary care physician.Ms.
J's primary care physician has followed her for many years and has made the diagnosis of somatization disorder.
86. The nurse finds that the client with a somatoform disorder has physical symptoms present, but there is no
evidence of physiologic disease. The client may have decreased amounts of serotonin and endorphins, causing
the client to experience an increased sensitivity to pain. This explanation of the client's symptoms is based in:
a. Communication theory.
b. Humanistic theory.
c. Genetic theory.
d. Biologic theory.
Answer: D
Research has shown that brain abnormalities such as decreased serotonin and endorphins may lead to altered
pain perception. Genetic theorists believe that both genetic and environmental factors contribute to somatization
disorders. Communication theorists believe somatization is nonverbal body language intended to communicate a
message to significant others. Humanistic theorists believe one must look at clients with somatoform disorders in
the context of what is happening in the clients' lives.
Reference: Deborah Antai-Otong, Psychiatric Nursing:Biologic and Behavioral concepts. 2nd edition
87. When working with a client who has a somatization disorder, it is most important for the nurse to:
a. Attend to the client's needs immediately
b. Have the client keep a journal of the symptoms
c. Provide pain medication around the clock as ordered instead of as needed
d. Recognize manipulative behavioral patterns and avoid reinforcing dependency
ANSWER: D
The nurse does not want to reinforce symptoms, manipulative behavioral patterns, or dependency.
Reinforcement of these behaviors encourages secondary gain from the illness. The goal of treatment would be for
the client to identify more effective methods for dealing with stress.
Reference: Deborah Antai-Otong, Psychiatric Nursing:Biologic and Behavioral concepts. 2nd edition
88. When taking a health history from a client with somatization disorder, you would most expect to find:
a. A stable interpersonal relationship with one partner
b. A long-time relationship with one health care provider
c. That the client is vague on many aspects of the information
d. A calm, matter-of-fact presentation of many unremarkable ailments
ANSWER: C
The client is typically a vague historian but the presentation is often dramatic with reports of detailed and
complicated medical problems. He has difficulties with relationships. He often sees more than one health provider
at a time in an attempt to validate that a real physical condition exists.
Reference: Deborah Antai-Otong, Psychiatric Nursing:Biologic and Behavioral concepts. 2nd edition
89. During assessment, the nurse will find that the client who has a diagnosis of body dysmorphic disorder will
have which of the following symptoms?
a. dissatisfaction with body shape and size
b. preoccupation with an imagined defect in appearance
c. fantasizing oneself as changed into an ideal appearance
d. a history of eight or more plastic surgeries on various body parts
ANSWER: B
Body dysmorphic disorder involves preoccupation with an imagined defect in appearance. The imagined defect is
not apparent to others who see the client as normal.
Reference: Deborah Antai-Otong, Psychiatric Nursing:Biologic and Behavioral concepts. 2nd edition
90. The client states that she has been ill and in pain since childhood. Her many symptoms are not caused
intentionally, nor are they feigned. She has seen many doctors. Consistent with this client's disorder, the nurse
believes the pain the client experiences is:
a. For attention.
b. Fake.
c. Real.
d. Exaggerated.
Answer: C
This client has somatization disorder and is genuinely experiencing pain. It is not fake, for attention, or
exaggerated.
Reference: Kneisl C.R. Contemporary Psychiatri-Mental Health Nursing 2nd edition
SITUATION: Susan is a 15-year-old girl with a 2-year history of body aches, fatigue, fevers (reported but not
documented), headaches, diarrhea, nausea, joint pain, dysuria, and irregular menses. During multiple medical
clinic visits, Susan repeatedly had normal findings on physical and extensive laboratory examinations. While
being evaluated by neurology department personnel for her headaches, Susan became completely mute.
Following a negative medical workup, she was admitted to a psychiatry inpatient unit, where she began talking
upon arrival. During this admission, she disclosed that her stepbrother had been sexually abusing her and her
mother's boyfriend had physically abused her for several years. But Susan subsequently recanted the allegations
of physical and sexual abuse.
91. The somatic symptoms are neither intentionally produced nor pretended and appear to be unconscious to the
patient. Susan met the criteria of somatization disorder on the basis of which of the following historical findings?
I. Body aches, headaches, joint pain, dysuria
IV. Nausea, diarrhea
II. Irregular menses
V. Mute
III. Fatigue, fevers
VI. Body ache, irregular menses, diarrhea, mute
a. I, II, III only
b. II, IV, V only
c. I, II, IV, V only
d. VI only
ANSWER: C
All the following historical criteria are required for a diagnosis:
Four different pain sites (eg, head, abdomen, back, joints, extremities, chest, rectum) or functions (eg,
menstruation, sexual intercourse, urination)
Two gastrointestinal symptoms other than pain (eg, nausea, bloating, vomiting not caused by diarrhea, or
intolerance of several different foods)
One sexual or reproductive symptom other than pain (eg, erectile or ejaculatory dysfunction, irregular menses,
excessive menstrual bleeding)
One pseudoneurological symptom (eg, impaired balance, paralysis, aphonia, urinary retention)
Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 433
92. The nurse manager informs a novice psychiatric nurse that stress is an essential component of somatoform
disorders due to which of the following?
a. Is the only feature of this disorder
c. Is appositive force in overcoming the illness
b. Exacerbates the illness
d. Is not a precursor to the development of this disorder
ANSWER: B
Stress is one key component that exacerbates and intensifies the somatoform clinical manifestations. Stress is
the only feature, however, because there are psychological, neurobiological and familial components as well.
Stress does not contribute to overcoming the illness. The presence of stress actually makes the condition worse.
Stress is precursor to developing somatoform disorder.
Reference: Ann Isaacs. Mental Health and Psychiatric Nursing. 4th edition. Page 76
93. Julia is a 15-year-old pregnant Alabang girl was brought to the emergency room with her right elbow held in
a flexion position and her left toe pointed downward in plantar extension. When asked about her symptoms, she
stated with little affect that, "I'll get used to it." Her presentation could not be explained by any known medical
condition and was subsequently diagnosed as a conversion disorder. She subsequently reported that her
boyfriend, who was the father of the baby, had recently started seeing another girl. The nurse evaluates that the
etiology of conversion disorder is which of the following?
a. Psychological in origin
b. Neurologic origin
c. Physical in origin
d. Organic in origin
ANSWER: B
Primarily conversion disorder is psychological in origin. A conversion disorder is psychologic disorder in which the
client exhibits physical clinical manifestations not explained by a physical or neurologic disorder.
Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 433-434
SITUATION: Jennifer is a mildly anxious and depressed 13-year-old adolescent girl who feared the possibility of
having cancer. She became convinced she had cancer when her breast development was asymmetrical. She felt
her hair was falling out, and, in her mind, this further confirmed her diagnosis. She was seen by her pediatrician,
who reassured her that her symptoms were normal and provided her with information about her normal physical
examination findings. The client was diagnosed with hypochondriasis.
94. Which of the following assessments are essential for the nurse to make before a diagnosis of hypochondriasis
can be made for the client?
a. The preoccupation of a medical malady is not better accounted for by another psychological disorder
b. The medical malady causes significant social and occupational impairment
c. The absence of delusional process
d. All of the above
ANSWER: D
Hypochondriasis is the fear of having a medical malady based on the incorrect interpretation of the body’s
function. There is no delusional process involved. The preoccupation with medical malady is no better accounted
for by another psychological disorder. The disorder generally has at least a 6-month duration. The medical
malady causes significant social or occupational impairment.
Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 433-435
95. When planning care for the client with hypochondriasis, the nurse should include which of the following?
a. Avoid focusing the preoccupation with the disease
b. Attempt to identify the sources of anxiety
c. Inform the client about normal sensations
d. Discourage the client from making frequent visits to health care specialists
ANSWER: B
The major treatment objective of hypochondriasis is to identify the source of anxiety and treat it. Ignoring the
client’s preoccupation with illness will escalate the behavior. Acknowledgement of the client’s concern with a
redirection toward the source of anxiety is more therapeutic. Telling the client about normal sensations does not
help the client deal with personal manifestations. Health care visits should be encouraged at routine times to
discourage overuse for the purpose of gaining attention.
Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 434
96. When the nurse monitors the client diagnosed with hypochondriasis, it is important that the nurse assesses
for which of the following behaviors?
a. The client’s increased ability to cope with anxiety
b. The client’s clinical manifestations move from the primary site to a secondary site
c. The client asks for more medication
d. The client reports additional clinical manifestations
ANSWER: A
The reduction of clinical manifestations is manifested in the ability to appropriately deal with psychological
anxiety. The client’s clinical manifestations need to abate rather than move. The need for an additional drug is
not a sign of dealing with hypochondria. The clinical manifestations should diminish rather than increase.
Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 434
SITUATION: Ruby was an attractive college student who complained of her face being slightly asymmetrical.
She felt this was the first thing that will be noticed about her; yet, it was almost an imperceptible feature. She
went to a craniofacial surgeon to try and have this corrected. In the doctor’s opinion, she was not disfigured, so
he sent her to a mental health specialist for evaluation. A psychiatrist confirmed the diagnosis of body
dysmorphic disorder.
97. Ruby asks the nurse about her disorder. Which of the following would be an appropriate response by the
nurse?
a. “There is no medical cause for your disorder”
b. “Because of your disorder, you will be exceptionally needy”
c. “Significant distress in social functioning is a result of your disorder”
d. “The defects you are experiencing are real”
ANSWER: C
Social isolation is a major contributor to a body dysmorphic disorder. It is a cyclical process in which the more
withdrawn the client becomes, the more dysmorphic belief will contribute to more withdrawal. The disorder will
become even more pronounced. There may be a minor problem, but the response to it is beyond reasonable.
Clients tend to avoid social contact because of self consciousness with the imagined defect. The defects the client
is experiencing are not real.
Reference: Videbeck. Pschiatric Nursing. 2nd edition Page 462-467
SITUATION: “Fear” is the normal response to a genuine danger. With phobias, the fear is either irrational or
excessive. It is an abnormally fearful response to a danger that is imagined or is irrationally exaggerated. People
can develop phobic reactions to animals (e.g., spiders), activities (e.g., flying), or social situations (e.g., eating in
public or simply being in a public environment). Phobias affect people of all ages, from all walks of life, and in
every part of the world.
98. Nurse Hannah is teaching a client who has social phobia about the drug Selective Serotonin Reuptake
Inhibitor (SSRI). The client asks Nurse Hannah how this drug will correct her “imbalance” problem. Which of the
following is the best response made by Nurse Hannah?
a. “I’m not allowed to answer that question, why don’t you ask the doctor for the purpose of your medication”
b. “I’m also unsure why your doctor gave this medication”
c. “What do you mean by “imbalance”?”
d. “There are times that our brain produces too little serotonin, and SSRI will correct this”
ANSWER: D
The nurse should tell the client that a SSRI produces the chemical serotonin in the brain of a client who naturally
produces too little. This is a simple but accurate explanation that makes sense of why this particular drug will
help. The nurse, along with the physician is responsible for medication education. This client already admitted to
knowing about it. The nurse is responsible for knowing what a chemical imbalance means.
Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 235-237
99. Nurse Mikee evaluates a client with dog phobia who has undergone desensitization. Which of the following
client’s behaviors would indicate that the treatment has been effective?
a. The client recalls how fear of dogs is both unreasonable and excessive
b. The client visits dog in the impound three times a week
c. The client states that his fear of dogs is greatly lessened
d. The client can pet the neighbor’s dog without undue anxiety
ANSWER: D
Success in phobic desensitization is shown when the client is able to do what the average person can do without
undue anxiety. Clients with phobias routinely believe their fears are unreasonable before treatment begins. A
client visiting dog impound three times a week and stating that fears are greatly diminished are both stepsin the
overall desensitization process, but they are not the end result.
Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 567
100. The husband of a client with phobia of water has planned a boat trip to Puerto Galera. He states, “Para
maalis na’tong takot niya sa tubig, dapat siguro eh biglain ko na siya”. The nurse’s most helpful response would
be which of the following?
a. “Mas lalo lamang makakasama sa kaniya ang ganiyang pamamaraan”
b. “Sumasangayon ako, magandang ideya ang bakasyon”
c. “Upang mas maging epektibo ang plano mo, gawin mo itong isang sorpresa”
d. “Naisangguni nyo ba ito sa ibang myembro ng pamilya?”
ANSWER: A
Intense exposure to feared stimuli without careful planning and the agreement of the client is likely to increase
clinical manifestations and decrease trust. Affirming the spouse’s comments shows the nurse’s lack of
understanding of the dynamics of phobia (Option B). Telling the spouse that such plan should be a surprise
demonstrates a lack of respecting the need for client involvement in the treatment planning (Option C). Asking
the client’s spouse if other family members’ opinion have been sought is beside the point.
Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 422-423
: Ann Isaac. Mental Health and Psychiatric Nursing. 4th edition. Page 55
MENTAL HEALTH AND PSYCHIATRIC NURSING
MOOD DISORDERS
SITUATION: Mood disorder is the term given for a group of diagnoses in the Diagnostic and Statistical Manual of
Mental Disorders (DSM IV TR) classification system where a disturbance in the person's mood is hypothesized to
be the main underlying feature.
1. Using cognitive-behavioral therapy. Which treatment would be appropriate for a client with depression?
a. Challenging negative thinking
c. Prescribing antidepressant medications
b. Encouraging analysis of dreams
d. Using ultraviolet light therapy
ANSWER: A
Cognitive-behavioral therapy includes identifying and challenging a client's negative cognitions. The belief is that
these negative thoughts influence the feelings and behaviors in depression. Dream analysis would be used in
psychoanalytic psychotherapy. Antidepressant medication could be part of a treatment program for an individual
with depression; however, this would not be considered cognitive-behavioral therapy. Ultraviolet light therapy
would be a somatic approach to treatment for seasonal affective disorder.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
2. While assessing a client diagnosed with bipolar disorder, the nurse would expect to find a history of:
a. A depressive episode followed by prolonged sadness.
b. A series of depressive episodes that reoccur periodically.
c. Symptoms of mania that may or may not be followed by depression.
d. Symptoms of mania that include delusional thoughts.
ANSWER: C
The definition of bipolar disorder is a mood disturbance in which the symptoms of mania have occurred at least
one time. Depression mayor may not occur as a separate episode in bipolar disorder. None of the other options
indicate a correct understanding of bipolar disorder.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
3. A client completing requirements for student teaching reports to the nurse an incident in which a student was
rude and disrespectful. The client states, "none of the students respects my teaching ability” The nurse identifies
this as an example of which common negative cognition?
a. Labeling
b. Fortune telling
c. Overgeneralization
d. "Should" statement
ANSWER: C
The client in this situation is overgeneralizing the response of one particular student, inferring that the entire
class has this attitude and blowing the incident out of proportion. Labeling is the application of negative labels to
oneself or others. Fortune telling is the conviction that things will not turn out right, despite evidence to the
contrary. "Should" statements refer to statements establishing standards for self and others.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
4. Which of the following behaviors in a client with a diagnosis of bipolar disorder, single manic episode, would
the nurse expect to assess?
a. Apathy, poor insight, and poverty of ideas
c. Elation, hyperactivity, and impaired judgment
b. Anxiety, somatic complaints. and in¬somnia
d. Social isolation, delusional thinking. and clang associations
ANSWER: C
A client with bipolar disorder, manic episode, would demonstrate flight of ideas and hyperactivity as part of the
increased psychomotor activity. The mood is one of elation and the feeling is that one is invincible; therefore,
judgment may be quite impaired. The symptoms in option 1 would be more characteristic of an individual with
long-term schizophrenia. The symptoms in option 2 would be more characteristic of someone with an anxiety
disorder, although a manic individual may also not sleep because of excessive energy. The symptoms in option D
are more characteristic of schizophrenia.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
5. A manic client is creating considerable chaos in a day-treatment program, behaving in a dominating and
manipulative way. Which nursing intervention is most appropriate?
a. Allow the peer group to intervene
b. Describe acceptable behavior and set realistic limits with the client
c. Recommend that the client be hospitalized for treatment
d. Tell the client that his behavior is inappropriate
ANSWER: B
In this situation, it would be appropriate for the nurse to suggest alternative behaviors in place of unacceptable
ones to help the client gain self-control. The peer group is not responsible for monitoring the client's behavior.
The client's behavior does not warrant hospitalization. Option D is inappropriate because the client is told only
what is unacceptable and is not given any alternatives.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
6. According to the biogenic amine theory, an individual with depression has a deficiency in which
neurotransmitters?
a. Dopamine and thyroxin
c. Cortisone and epinephrine
b. GABA and acetylcholine
d. Serotonin and norepinephrine
ANSWER: D
The biogenic amine theory of depression describes deficiencies in the neurotransmitters serotonin and
norepinephrine. Antidepressant medications increase the levels of these neurotransmitters and therefore help to
relieve depressive symptoms. According to current research, dopamine, thyroxin, GABA, acetylcholine, cortisone,
and epinephrine are not directly related to depression.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
7. The nurse is teaching a client and her family about the causes of depression. Which of the following causative
factors should the nurse emphasize as the most significant?
a. Brain structure abnormalities
c. Social environment
b. Chemical imbalance in the brain
d. Recessive gene transmission
ANSWER: B
Chemical imbalance of neurotransmitters in the brain is the most significant factor in depression. However, the
exact cause has not been established, so other factors may also be involved. Although genetic transmission
certainly may be a factor; no definite pattern of transmission has been identified. A person's social environment,
including lack of support systems, may also increase the risk of depression.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
8. When evaluating for imminent suicide risk, which information given by the client would be most significant?
a. At least a 2-year history of feeling depressed more days than not
b. Divorced from spouse 6 months ago
c. Feeling loss of energy and appetite
d. Reference to suicide as best solution to identified problems
ANSWER: D
An individual who talks about suicide as a solution to problems is at high risk. This client's suicidal threats need to
be taken seriously because he does not see any other viable solutions to problems in living. All of the factors
included in the other options would increase the client's risk for depression; however, actual statements about
suicidal intent are red flags indicating imminent danger.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
9. A client in an acute psychiatric hospital unit tells a nurse about his plans for suicide. The nurse's priority is to:
a. Allow the client time alone for reflection.
c. Follow agency protocol for suicide precautions.
b. Encourage the client to use problem solving.
d. Stimulate the client's interest in activities.
ANSWER: C
The nurse must act to safeguard the client from danger, including self-harm. Implementing the specific agency
protocol for suicidal precautions would best protect the client. A client with suicidal in tent should not be left
alone. One-to-one observations are generally part of suicide precautions. Encouraging the client to problem
solving and stimulating his interest in activities would be helpful for someone with depression; however, the
nurse's priority is to protect the client initiating suicide precautions.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
10. Which mood disorder is characterized by the client feeling depressed most 0 the day for a 2-year period?
a. Cyclothymia
b. Dysthymia
c. Melancholic depressive disorder
d. Seasonal affective disorder
ANSWER: B
Dysthymia is characterized by at least 2-year history of depression, occurring most of the day for more days than
not. Cyclothymia is characterized by at least 2 years of several periods of hypomanic symptoms. Melancholic
depressive disorder is characterized by either anhedonia in relation to all activities or lack mood reactivity to
usually pleasurable stimuli. Seasonal affective disorder is characterized by depressed feelings in fall winter,
associated with loss of sunlight
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
11. The community nurse is speaking to group of new mothers as part of a primary prevention program. Which
self-care measures would be most helpful a strategy to decrease the occurrence mood disorders?
a. Keeping busy, so as not to confront problem areas
c. Use of crisis intervention services
b. Medication with antidepressants
d. Verbalizing rather than internalizing feelings
ANSWER: D
Individuals who develop mood disorder often have difficulty expressing feelings especially feelings of anger
toward significant others. Internalizing those feelings can tribute to loss of self-esteem and guilt, therefore
negative cognitions and depression. Ignoring problems is not a helpful strategy. Recognizing problems and using
problem-solving methods will contribute to mental health. Antidepressants are certainly necessary in the
treatment of the mood disorder of depression; however, they are not used in primary prevention. Crisis
intervention would be a useful strategy in handling the immediate needs of someone experiencing a crisis; it is
not a tool of primary prevention.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
12. The husband of a client who has recently lost her job tells the clinic nurse that the client's moods are
constantly changing from extremely happy and elated sadness and crying. As part of an immediate assessment
of the family situation, the nurse should question the husband and wife about which of the following?
a. The client's academic and work history
b. The specific history of psychopathology in the client's family
c. The client’s specific symptoms, duration of the symptoms, and the impact of the symptoms on the family
d. The quality of the couple's marital relationship
ANSWER: C
Assessment of the current family situation would include identifying the client's symptoms, duration of
symptoms, and the unique impact on this particular family. The assessment data related to options A and B
would be important, but the immediate assessment would be more specific to the current family crisis. The
quality of the marital relationship would be one aspect of the entire family situation.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
13. During a daily community meeting, a client with bipolar disorder, manic type. begins pacing around the room
and speaking rapidly in a loud voice. Which nursing intervention is most appropriate?
a. Ask the client to accompany the nurse and move to a quieter room
b. Allow the community group to handle the client's behavior
c. End the community meeting at this time
d. Offer the client an antianxiety medication
ANSWER: A
The most appropriate intervention when a client's mania begins to escalate is to remove him from an
overstimulating environment (the community meeting) and lead him to a quieter setting, thereby helping him
regain self-control. This is the least restrictive intervention and should be offered prior to the use of antianxiety
medication (a form of chemical restraint). In this situation, the community group may be intimidated by the
client’s behavior and reluctant to intervene; also the nurse is responsible for limit setting and intervention when
client behavior is inappropriate. The community meeting is an important forum for client participation and should
not be terminated because one client is upset.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
14. The nurse teaches the family of a client with major depression disorder. Which of the following information
should be included in the teaching?
1. Depression is characterized by sadness, feelings of hopelessness and decreased self-worth
2. It is common for a pressed individual to have thoughts of suicide
3. Attempts to cheer up a person with depression are often helpful
4. Talk therapy along with antidepressant medications is usually the treatment
5. Someone with depression may be preoccupied with spending money and too busy to sleep
6. Encourage a person with depression to keep a regular routine of activity and rest
a. 1, 2, 3, 4
b, 1, 2, 4, 5
c. 1, 2, 4, 6
d. All except 3
ANSWER: C
These statements about major depressive disorders provide correct information and will be helpful to the client's
family. Option 3 is incorrect; it is better to acknowledge the client's sad mood and offer reassurance that his
mood will improve. Option 5 is more characteristic of someone in a manic phase of bipolar disorder.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
15. The physician gives a prescription for a tricyclic antidepressant to a client. When the nurse talks with the
client after she receives the prescription, the client mentions that she has glaucoma. Which of the following
actions by the nurse would be most appropriate?
a. Ask the client to wait so the physician can be made aware of the glaucoma.
b. Make a note of the glaucoma in her chart and stress the importance of an annual eye exam.
c. Advise the client that she will have to take a different antidepressant.
d. Thank the client for telling you as this will mean the dosage will need changing.
ANSWER: A
The nurse needs to notify the doctor immediately of the glaucoma. The doctor will then need to determine the
type of glaucoma the client has. A client with narrow-angle glaucoma may experience increased eye pressure due
to mydriasis (excessive pupil dilation) when taking a tricyclic antidepressant. It will be up to the physician to
decide on the best course of action for this client. The nurse should also document the information in the client's
chart.
Reference: Norman Keltner. Psychiatric Nursing 5th edition Page 246
16. A client in the inpatient psychiatric unit had been prescribed a MAIO antidepressant recently, and it was
unsuccessful in relieving the depression. After one week, the physician prescribed a serotonin reuptake inhibitor.
When the medication nurse approaches the client to give the drug, she notices some changes in the client's
mental status. The client is very agitated and is complaining of muscle spasms, abdominal cramps, nausea and a
headache. She is sweating and shivering at the same time. What is the most appropriate next action of the
nurse?
a. Give the medication, and notify the supervising nurse.
b. Hold the medication and notify the physician immediately.
c. Give the medication and isolate the client immediately.
d. Hold the medication until the client is not nauseated.
ANSWER: B
The client is most likely experiencing serotonin syndrome. It is related to excess serotonin activity. It is best to
wait a full 2 weeks between the discontinuing of a MAOI and the starting of a SSRI to give the former drug time
to be completely cleared from the body. The nurse should hold the medication and notify the physician
immediately.
Reference: Amy Karch. Focus on Nursing Pharmacology. 3rd edition Page
17. The nurse is checking the laboratory results on a client who is on lithium for symptoms associated with
bipolar disorder. The nurse observes that the lithium level is higher than normal but not yet toxic. Which of the
following behaviors on the part of the client would most likely account for this elevated lithium level?
a. Drinking an excessive amount of water and fluids.
c. Not getting sufficient sleep and rest.
b. Starting on a salt-free or low salt diet.
d. Taking several lithium tablets one at a time.
ANSWER: B
Lithium is a salt, and because of this, the sodium and fluid balance of the body will affect lithium levels. Low
sodium levels could lead to lithium toxicity. The fluid intake should be at least 2000 to 3000 ml/day. The diet
should contain a moderate amount of sodium. Not getting enough rest and sleep would not predispose the client
to toxicity. A toxicity could result from taking an overdose of the drug, but that is not the most likely cause of this
client's condition.
Reference: Norman Keltner. Psychiatric Nursing 5th edition Page 258
18. A client has a diagnosis of bipolar disorder. He is currently in a manic state. He is losing weight and the
treatment team has decided on a nursing diagnosis of imbalanced nutrition: less than body requirements. Which
of the following would be an appropriate intervention to ensure the client receives adequate nutrition?
a. Restrain the client at mealtime, so that he must remain at the table and eat his food.
b. Offer him frequent nutritious "finger foods" that he can eat while walking.
c. Obtain an order for an anti-anxiety drug to calm him down, so he can sit down and finish a meal.
d. Reduce his fluid intake, so he is more likely to eat solid foods.
ANSWER: B
The most likely reason that a client experiencing the mania of Bipolar Disorder is losing weight is due to excess
activity. S/he might be burning up more calories than taking in. Therefore, providing the client with nutritious
"finger foods" and fluids often is imperative to prevent weight loss. Restraining the client is a violation of his
rights, as he is not dangerous to himself or others. Giving him a medication is just another type of restraint. He
needs plenty of fluids to avoid dehydration.
Reference: Norman Keltner. Psychiatric Nursing 5th edition Page
19. The physician orders electroconvulsive therapy (ECT) for a severely depressed client who fails to respond to
drug therapy. When teaching the client and family about this treatment, the nurse should include which most
important point about ECT?
a. An anesthesiologist will administer ECT
c. ECT will induce a seizure
b. ECT can cure depression
d. The client will remember the shock of ECT but not the pain
ANSWER: C
Reserved for clients with acute depression who don't respond to pharmacologic or psychiatric measures, ECT is
the passage of an electrical current through the brain to induce a brief seizure. According to ECT proponents, the
seizure causes desirable changes in neurotransmitters and receptor sites similar to those caused by
antidepressant drugs. ECT is administered by a physician or an anesthesiologist. Although ECT may reduce the
severity of depression, it doesn't necessarily cure it. Before ECT, the client receives a medication that provides
short-term amnesia of the entire event.
20. A client diagnosed with major depression has started taking amitriptyline (Elavil), a tricyclic antidepressant.
What is a common adverse effect of this drug?
a. Weight loss
b. Dry mouth
c. Hypertension
d. Muscle spasms
ANSWER: B
Tricyclic antidepressants can have anticholinergic adverse effects, with dry mouth being the most common.
Hypotension would be expected, rather than hypertension. Weight gain — not loss — is typical when taking this
medication. Muscle spasms aren't an adverse effect of tricyclic antidepressants.
Reference: Norman Keltner. Psychiatric Nursing 5th edition Page 246
21. Which nursing intervention would be most appropriate if a client were to develop orthostatic hypotension
while taking amitriptyline (Elavil)?
a. Consulting the physician about substituting a different type of antidepressant
b. Advising the client to sit up for 1 minute before getting out of bed
c. Instructing the client to double the dosage until the problem resolves
d. Informing the client that this adverse reaction should disappear within 1 week
ANSWER: B
To minimize the effects of amitriptyline-induced orthostatic hypotension, the nurse should advise the client to sit
up for 1 minute before getting out of bed. Orthostatic hypotension commonly occurs with tricyclic antidepressant
therapy. In these cases, the dosage may be reduced or the physician may prescribe nortriptyline, another
tricyclic antidepressant. Orthostatic hypotension disappears only when the drug is discontinued.
Reference: Norman Keltner. Psychiatric Nursing 5th edition Page
23. The nurse is monitoring a client receiving tranylcypromine sulfate (Parnate). Which serious adverse reaction
can occur with high dosages of this monoamine oxidase (MAO) inhibitor?
a. Hypotensive episodes
b. Hypertensive crisis
c. Muscle flaccidity
d. Hypoglycemia
ANSWER: B
The most serious adverse reaction associated with high doses of MAO inhibitors is hypertensive crisis, which can
lead to death. Although not a crisis, orthostatic hypotension is also common and may lead to syncope with high
doses. Muscle spasticity (not flaccidity) is associated with MAO inhibitor therapy. Hypoglycemia isn't an adverse
reaction of MAO inhibitors.
Reference: Norman Keltner. Psychiatric Nursing 5th edition Page
24. During family support group, a family member asks: “How is bipolar disorder different from depression?”
Which of the following is the best response?
a. “Sleep patterns, self-care, and intake are affected only in depression.”
b. “People with bipolar disorder do not seek help. People with depression readily seek treatment from health care
providers.”
c. “Often, individuals with bipolar disorder can feel elated, are productive, and do not think there is anything
wrong when they have manic feelings.”
d. “Individuals with bipolar disorder start out happy enough, but they eventually develop irritability.”
ANSWER: C
Clients with bipolar disorder frequently report that they enjoy the “highs” of mania. Mood stabilizers mediate this
elation and many clients report this therapeutic impact as a reason for nonadherence to the treatment regimen.
In contrast, clients with major depression report feeling “bad,” even if they do not describe themselves as having
a mood disorder. Option A: This statement is not accurate and does not answer the question. Option B: Clients
with depression may not identify their experience as a psychiatric disorder, and they are often withdrawn and
reject help.
Option D: Individuals with depression often become irritable and angry, with outbursts that isolate them from
others. People with bipolar disorder also experience irritability, even when experiencing mania.
Reference: Carol Ren Knseil. Contemporary Psychioatric-Mental Health Nursing 2nd edition
25. Your client states, “Many of the people in my family experience similar symptoms with each depressive
episode. Does that mean that we have the same genetic defect?” Your best response includes which of the
following?
1. “Heredity does seem to play a role in mood disorders. You and your family members may have the same
biologic predisposition.”
2. “Related symptoms are probably due to being raised in the same family and learning the same behavioral
responses.”
3. “Most current theories focus on electrolyte disturbances, particularly the reversal of sodium and potassium in
the neurons of depressed individuals.”
4. “There are probably several genetic or biologic abnormalities associated with depression.”
5. “With the wide variety of mood disorders, a biological basis is not likely. Therefore, pharmacological
treatments for your family members should be individualized.”
a. 2, 3, 4
b. 1, 2, 5
c. 1 and 4 only
d. All except 3
ANSWER: C
Option 1: The incidence of depression is higher among relatives of depressed individuals than in the general
population.
Option 4: Families may have a number of individuals with various psychiatric disorders, but disruption in the
experience of moods can indicate a genetic predisposition.
Option 2: Based on current theory, it is more likely that their presentations are associated with similar related
biochemistry. This response does not address current biopsychosocial theory.
Option 3: Current research has focused on the role of certain chemicals, the neurotransmitters, in the central
nervous system. Therefore, this response does not address the critical role of neurotransmitters in mood
disorders.
Option 5: There does seem to be a biopsychosocial (multifactorial) basis for depression. During a psychosocial
history, many health care providers collect data regarding the diagnoses of family members and which
medications have been effective for them. This can be useful information for treating other family members.
Reference: Carol Ren Knseil. Contemporary Psychioatric-Mental Health Nursing 2nd edition
SITUATION: A 39-year-old married woman with 2 children, ages 16 and 12 years was electively admitted for
treatment of worsening depression. She had a 5-year history of recurrent severe depressive episodes; there had
been no history of mental health problems prior to this. She had been an in-patient for most of the last 5 years,
and had been required to be on a one-on-one nursing care because of self-directed violence, which included
cutting and trying to set herself on fire.
26. Which of the following nursing interventions is a priority when assessing a client for suicide?
a. Ask the client directly, “Do you have plans to kill yourself?”
b. Get the client to the hospital for further evaluation
c. Assess the client for suicidal risk, method, and ability to carry out the plan
d. Assess for past suicide attempts
ANSWER: C
Assessing the client is necessary before determining if the client needs to be hospitalized or not. Assessing past
suicide is very important as well as asking if the client has a plan to kill herself. Asking if the client has a plan,
assessing past suicide attempts, or taking the client to the hospital are also important interventions, but the
priority is to determine if the client has a plan.
Reference: Videbeck. Psychiatric Mental Health Nursing. Page 337-340
27. A diagnosis of major depressive disorder has been made. The client asks the nurse what is the difference
between a major depression and a bipolar disorder. The most appropriate response by the nurse is:
a. “Major depression and Bipolar disorder are two different mood disorders, but the treatment is the same”
b. “Bipolar disorder is an upswing of mood while major depression is downward mood swing. They require very
similar treatment modalities.”
c. “Major depression is a downward swing of mood with treatment, including mood stabilizers, where as bipolar
depression is an upward swing with antidepressants given to bring the mood down”
d. “Major depression is a depressed mood state that requires antidepressant medication while bipolar disorder is
an upward swing of mood that requires mood stabilizers for treatment”
ANSWER: D
Major depression and bipolar disorder are two different mood disorders with different treatment regimens. Major
depression is a downward swing of mood, and bipolar disorder is an upward swing of mood (mania) and a
downward swing of mood (hypomania). Major depression is treated with an antidepressant, while bipolar disorder
is treated with a mood stabilizer such as gabapentin (Neurontin)
Reference: Videbeck. Psychiatric Mental Health Nursing. Page 312-313
28. A patient who is being treated for depression has been taking Imipramine (Tofranil) for five days. The patient
complained about not feeling better. Which of the following statements is appropriate?
a. “A higher dose is needed”
b. “The doctor may need to change the brand of your medication”
c. “The drug takes 2-3 weeks to become effective”
d. “Another route of administration is indicated”
ANSWER: C
TCA may take 2-3 weeks to be effective, MAOI’s need 2 to 4 weeks for effectiveness; and SSRI’s may be
effective in 2 to 3 weeks.
Reference: Videbeck. Psychiatric Mental Health Nursing. Page 34.
Louise Shives. Psychiatric Mental Health Nursing. 7th edition. Page 235
29. A client is taking phenelzine (Nardil) as his medication. Which of the following would the nurse anticipate as
possible issue for the client’s adherence to this medication regimen?
a. It requires dosing several times a day, thus a decreasing compliance
b. It has the potential for serious interactions with other medications
c. It requires adherence to strict diet
d. It has been found to be ineffective in treating psychiatric disorder
ANSWER: C
Monoamine oxidase inhibitors such as Nardil, interact with tyramine found in many foods, thus requiring the
individuals using these drugs to follow a strict diet. Compliance becomes an issue. Foods high in tyramine include
aged cheese, slami, avocados, chocolate, coffee, beer and wine containing yeast.
Reference. Norman Keltner. Psychiatric Nursing. 5th edition. Page 249
30. Which of the following is a priority to include in the plan of care for a client taking fluoxetine (Prozac)?
a. Monitor the client for Postural hypotension
c. Wait for 2 weeks after taking a MAOI before starting Prozac
b. Give with food
d. Administer simultaneously with (thioridazine) Mellaril
ANSWER: C
Prozac is a SSRI antidepressant. The client should be monitored for postural hypotension and instructed to
change positions with caution. Prozac may be administered with food to decrease GI upset. It is a priority to wait
for 14 days after discontinuing a MAOI and administering Prozac. Five weeks should pass between stopping
Prozac and starting a MAOI. Prozac should not be administered with Mellaril.
Reference. Norman Keltner. Psychiatric Nursing. 5th edition. Page 240
31. Tricyclic Antidepressants achieve their effects by:
a. Selectively blocking the uptake of serotonin.
c. Inhibition of enzymes
b. Blocking cholinergic receptors
d. Inhibits dopamine uptake
ANSWER: B
TCAs block the cholinergic receptor resulting in anticholinergic effects. Option A: action of SSRIs, first line agents
for treatment of depression. Option C is the action of MAOI inhibitors. Option D: is the action of Norepinephrine
and dopamine reuptake inhibitors (NDRI’s). Busprion (Wellbutrin) is the only drug for this category.
Reference. Norman Keltner. Psychiatric Nursing. 5th edition. Page 233-234
32. A patient who began taking a tricyclic antidepressant was given instructions regarding its use. Which of these
comments would indicate that the patient understands the information?
a.”This medicine will cause diarrhea, but I guess I can tolerate it”
b. “I will avoid cheese while I’m taking this medication”
c. “I will expect to be better in a week”
d. “I will chew sugarless candy if I experience drying of my mouth”
ANSWER: D
TCA block cholinergic receptors, resulting in anticholinergic effects such as dry mouth, constipation, urinary
hesitancy or retention, dry nasal passages and blurred vision. Chewing sugarless candy, sucking on hard candy,
or taking ice chips or sugar free soda will help relieve dry mouth. Therapeutic level will be achieved in 2-3 weeks.
Option C: intervention for client taking MAOI inhibitors, tyramine-rich foods such as cheese will cause
hypertensive crisis.
Reference: Videbeck. Psychiatric Mental Health Nursing. 3rd edition. Page 34
33. When distinguishing whether a client is suffering from depression or anxiety, the nurse recognizes that the
following would not be present in anxious clients, except?
a. Sleep disturbances
c. Irritability
b. Gastrointestinal complaints
d. Seeing some prospect for the future
ANSWER: D
Depressed clients see the future as a blank and have given up all hope where the anxious client has not. All
other symptoms are shared by clients experiencing two conditions. Both also experience difficulty concentrating;
appetite changes, and non specific cardiopulmonary complaints
Reference: Louise Shives. Psychiatric Mental Health Nursing. 7th edition. Page 283
34. Nurse Daniel is preparing to care for a client with major depression. Assessing which of the following would
be the priority nursing intervention for this client?
a. Risk for suicide
c. Current mood and activity level
b. appetite and weight
d. Response to medication administration
ANSWER: A
While it is important for the nurse to assess the client’s functioning, current mood and fluid and electrolyte
balance, assessing suicide risk of the client with major depression takes priority
Reference: Louise Shives. Psychiatric Mental Health Nursing. 7th edition. Page 610-611
35. Which of the following is the priority nursing intervention to encourage a depressed client discuss any suicidal
thoughts?
a. Instruct the client about the consequences of suppressed anger
c. Avoid discussion of depressing topics
b. Focus on the need to keep the client safe
d. Encourage to verbalize feelings
ANSWER: D
The best plan for a nursing intervention for the client who may be contemplating suicide is to encourage the
client to discuss feelings, because this will allow the nurse to understand the client’s emotional state and the
client’s mood. Options A,B, and C are not a priority nursing interventions
Reference: Videbeck. Psychiatric Mental Health Nursing. Page 161, 335-338
SITUATION: A 28-year-old single female arrives at a mental health clinic complaining of depression.
36. The client states that she has been feeling numb and empty most of the time and has little energy to perform
her usual activities. She has experienced these difficulties since the death of her best friend 6 months ago. Which
of the following is the nurse's best response?
a. Tell the client that the physician will prescribe an antidepressant and she will feel better
b. Encourage the client to get on with her life and stop feeling sorry for herself
c. Advise the client that it isn't unusual for grieving and loss to continue for quite some time
d. Suggest that the client return in 3 months if the feelings persist.
ANSWER: C
This provides the client with validation and support for her feelings. The other options neither validate the client's
bereavement nor allow her to resolve them.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 312-313
37. The client comes visits the clinic again after a year with more serious problems and has been diagnosed with
depression. She tells the nurse, "I won't allow myself to cry because it upsets the whole family when I cry." This
is an example of:
a. manipulation
b. insight
c. rationalization
d. repression
ANSWER: C
Rationalization is a defense mechanism used to justify actions or feelings with seemingly reasonable
explanations.
Option A - Based on the information provided, the client doesn't seem to be manipulating those around her.
Option B - Insight is comprehension of one's own behavior, often followed by an attempt to change it.
Option D - Repression is involuntary exclusion of painful and conflicting thoughts or feelings from awareness.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 312-313
38. She started taking amitriptyline (Elavil), a tricyclic antidepressant. What is a common adverse effect of this
drug?
a. Weight loss
b. Weight gain
c. Increased BP
d. Muscle spasms
ANSWER: B
Weight gain not loss is typical when taking this medication. It also has an anticholinergic side-effect
Option C - Hypotension would be expected, rather than hypertension.
Option D - Muscle spasms aren't an adverse effect of tricyclic antidepressants.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 314
39. The client states, "Everything is my fault, and I'd be better off dead." What's the priority nursing
intervention?
a. Assess the seriousness of the client's comment
c. Assign staff members to a suicide watch
b. Notify the psychiatrist of the client's verbalization
d. Engage the client in a no-suicide contract
ANSWER: A
This situation demands an accurate assessment of the client's suicide potential. The other options require more
thorough assessment data before implementation
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 312-313
40. After a suicide attempt, the client tells the nurse that she no longer wants to die. The nurse should:
a. Suggest that the client no longer requires close observation.
b. Place the client in a private room, away from the nurses' station, so that she has privacy to work through the
stages of the grieving process.
c. Inspect the client's personal belongings for potentially dangerous objects.
d. Avoid any further discussion of suicide, unless the client brings up the topic.
ANSWER: C
The client must be protected from harming herself. This includes checking all personal items that the client
brought to the hospital, such as a suitcase or pocketbook.
Option A - The client must be closely observed until she has been evaluated and receives treatment.
Option B - A client who is suicidal should be placed in a room near the nurses' station in full view of a nurse or
other observer.
Option D - The nurse shouldn't ignore the client's suicide attempt. The client may feel relief talking about the
suicide attempt and knowing that she'll be protected from harm.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 335-337
41. Which of the following patients should a nurse recognize as being at greatest risk of suicide?
a. A middle-aged divorced male who recently lost his job
b. An elderly married male in chronic pain
c. A young single female who had a miscarriage
d. An adolescent female who just broke up with her boyfriend
ANSWER: A
Option A has the most risks and losses.
Suicide is the intentional act of killing oneself.
Suicide risks:
•
History of previous suicide attempts
•
Men commit more suicide then men (USA)
•
Women are 4x more likely than men to attempt suicide
•
Clients with psychiatric disorders
•
Recent loss
•
Lack of social support
•
Unemployment
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 361
42. Mr. Santos calls the nurse and tells her that he blames himself for the death of his wife. Among the
symptoms and the verbalizations of Mr. Santos, which should concern the nurse the most?
a. Guilt about what was done at the time of his wife’s death
b. A morbid preoccupation with worthlessness and hopelessness
c. Expressed thoughts of being better of dead
d. Occasional shortness of breath and fatigue
ANSWER: C
Options B, C and D are not uncommon for the individual who is grieving and showing signs of depression. All of
them should concern the nurse. However, the first priority here is safety.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 332
43. In caring for a client at risk for suicide, the most important nursing action is to:
a. Maintain constant awareness of the client’s whereabouts
b. Ignore the client as long as the client is talking about suicide, because a suicide attempt is unlikely
c. Relax vigilance when the client seems to be recovering from depression
d. Administer medication as ordered
ANSWER: A
The client must be constantly observed.
B – All suicidal talk and gestures are to be taken seriously. If the client talks about suicide, there may be an
attempt.
C – Suicide risk is greater when depression is lifting, requiring greater vigilance.
D – Medication for depression may take up to 2 weeks to decrease symptoms, and the client needs vigilant
surveillance NOW.
Source: Tutor-Davis’s NCLEX-RN Success, 2nd edition
44. Using Peplau’s theory, when a client has resolved his or her initial suicidal crisis, the nurse in an acute care
setting will:
a. Terminate the relationship, ensuring that the client has a support system
b. Continue to be friends with the client as long as needed
c. Provide ongoing social support until the client has a support system
d. Explore an ongoing longitudinal study or extended relationship
ANSWER: A
Using Peplau’s theory, when a client has resolved his or her initial suicidal crisis, the nurse in an acute care
setting will terminate the relationship, ensuring that the client has a support system. The client should be able to
identify when help is needed and from which resources (support system) from this help can be obtained. Because
the nurse-client relationship is a professional relationship, the nurse ethically should not continue to be involved
with the client in a nonprofessional manner.
Reference: Firsch. Psychiatric Mental Health Nursing 4th edition
45. You notice that one of your assigned clients who has been very depressed suddenly seems to have more
energy. The client's significant other expresses relief that the client is better and wants to have the client
discharged from the hospital. Your best course of action would be to:
a. Advise the significant other that they must wait until the physician comes
b. Notify the physician about this sudden change in energy level and chart it
c. Check with the client to see if she wants you to call the physician about discharge
d. Ask the client about any suicidal ideation and educate the significant other about suicide
ANSWER: B
The nurse’s best course of action would be to notify the physician of the client’s sudden change in energy level.
This information should also be documented on the client’s chart. Depressed persons tend to commit suicide
when the depression lifts enough to provide the energy needed to complete the suicide. The client may not
answer the question about suicidal ideation truthfully if the intent to commit suicide is present. Also, discharge in
this situation could possibly result in the client’s committing suicide.
Reference: Antai-Otong. Psychiatric Health Nursing: Biologic and Behavioral Concept 2nd edition
46. A client who attempted suicide by slashing her wrists is transferred from emergency department to the
psychiatric unit of a community hospital. When the client arrives on the unit, the priority intervention should be
to:
a. Obtain the client’s vital signs
c. Inspect the bandages for signs of bleeding
b. Initiate a therapeutic relationship
d. Institute continuous observation of the client
ANSWER: D
This action protects the client from acting on suicidal thoughts and provides a sense of security.
A- Although this may be done eventually, it is not the priority.
B and C- Although this is important, it is not the priority.
Source: Mosby’s Comprehensive Review of Nursing, 18th Ed.Saxton et. al, p. 659
47. After admission, the nurse needs to evaluate a depressed client’s potential for suicide. The approach that
would best gain this information would be to ask:
a. The client about plans for the future
b. The client whether suicide is now being considered
c. Family members whether the client has ever attempted suicide
d. Other client about suicide while client is in the group
ANSWER: B
Directness is the best approach at the first interview, because this sets the focus and concern and lets the nurse
know what the client is feeling now.
At this point the client is most likely unable to think past the present, much less deal with future plans.
C- This would be one resource for input; but regarding suicide, it is best to approach the client directly.
D- This is an indirect approach, but initially the direct approach with the client is best.
Source: Mosby’s Comprehensive Review of Nursing, 18th Ed. Saxton et. al, p. 659
SITUATION: A woman is admitted to the psychiatric emergency department. Her significant other reports that
she has difficulty sleeping, has poor judgment, and is incoherent at times. The client's speech is rapid and loose.
She reports that she is a special messenger of the Messiah. She has a history of depression and has been taking
antidepressants.
48.
Based
on
the
assessment,
the
nurse
suspects
which
of
the
following
diagnosis?
a. Schizophrenia
c.
Bipolar
illness
b. Paranoid personality
d.
Obsessive-compulsive
disorder
(OCD)
ANSWER:
C
Bipolar illness is characterized by mood swings from profound depression to elation and euphoria. Delusions of
grandeur along with pressured speech are common symptoms of mania. Schizophrenia doesn't exhibit mood
swings from depression to euphoria. Paranoia is characterized by unrealistic suspiciousness and is often
accompanied
by
grandiosity.
OCD
is
a
preoccupation
with
rituals
and
rules.
Reference: Videbeck. Psychiatric Mental Health Nursing. Page 326
49. When assessing a client for bipolar disorder, the nurse should include which of the following assessments in
the mental status examination will help make a definitive diagnosis of a bipolar disorder?
a. Gait
b. Emotional developmental level
c. Mood
d. Nutritional status
ANSWER: C
While it is necessary to assess the client’s gait, emotional developmental level, and nutritional status, these are
not part of a mental status exam. Assessing the client’s mood (either mania, hypomania, or depression) would
provide the information needed to assist in verifying a diagnosis of bipolar disorder
Reference: Videbeck. Psychiatric Mental Health Nursing. Page 326
50. A nurse is educating a client about the possible signs of lithium toxicity. The following are signs of lithium
toxicity except:
a. Hand tremor
b. Metallic taste
c. Abdominal pain
d. Diarrhea
ANSWER: B
Lithium is an antimanic drug. Usual adverse reactions include headache, drowsiness, hypotension, dry mouth,
salty taste, and fatigue. Toxic adverse reactions include vomiting, diarrhea, tremors, abdominal pain, muscle
weakness, severe thirst, tinnitus, and dilute urine.
Reference: Louise Shives. Psychiatric Mental Health Nursing. 7th edition. Page 610-611
51. A 23-year-old client in the manic phase of bipolar disorder is admitted to the facility. Which agents would be
appropriate for this client?
a. Bupropion (Wellbutrin) and lithium (Lithobid)
c. Haloperidol (Haldol) and fluphenazine (Prolixin)
b. Lithium (Lithobid) and valproic acid (Depakote)
d. Risperidone (Risperdal) and clozapine (Clozaril)
ANSWER: B
Lithium and valproic acid (divalproex (Depakote)) are the drugs of choice for manic depression. Bupropion is an
antidepressant, not an antimanic. Haloperidol, fluphenazine, clozapine, and risperidone are antipsychotic agents.
52. The client with bipolar disorder is taking lithium carbonate (Lithonate). His serum lithium level is already
considered toxic if it is:
a. 0.5 mEq/L
b. 0.8 mEq/L
c. 1.0 mEq/L
d. 2.0 mEq/L
ANSWER: D
In a client taking lithium, the serum lithium level should be 1.0 mEq/L. Serum lithium level of less than 0.5
mEq/L are rarely therapeutic and levels of more than 2.0 mEq/L are considered toxic. Other books indicates a
level of 1.5-2.0 as toxic. The lithium level should be monitored every 2-3 days while the therapeutic dosage is
being determined, then weekly.
Note: Lithium toxicity – s/sx diarrhea, anorexia, fine hand tremors, metallic taste in the mouth, fatigue, lethargy
53. The physician orders lithium carbonate (Lithonate) for a client who's in the manic phase of bipolar disorder.
During lithium therapy, the nurse should watch for which adverse reactions?
a. Weakness, tremor, and urine retention
c. Constipation, lethargy, and ataxia
b. Anxiety, restlessness, and sleep disturbance
d. Nausea, diarrhea, tremor, and lethargy
ANSWER: D
The most common adverse effects of lithium (lithium toxicity) are nausea, diarrhea, tremor, and lethargy.
Lithium doesn't cause weakness, tremor, urine retention, anxiety, restlessness, sleep disturbance, constipation,
or ataxia.
54. The nurse evaluates which of the following lab values as the normal range for a client who is receiving
lithium?
a. 1.5 to 2.0 mEq/L
b. 0.1 to 0.5 mEq/L
c. 1.8 to 2.5 mEq/L
d. 0.6 to 1.2 mEq/L
ANSWER: D
Desirable maintenance blood levels are 0.6 to 1.2 mEq/L, which can be maintained on a dosage of 900 to 1200
mg/day.
Reference. Norman Keltner. Psychiatric Nursing. 5th edition. Page 256
55. Discharge teaching for a patient taking lithium should include which of the following except?
a. Suggest taking lithium with meals
b. Advice patient to drink 10 to 12 glasses of water a day
c. Maintain a consistent dietary sodium intake.
d. If a dosage is missed, take twice the amount at the next scheduled dose.
ANSWER: D
Option A: it is suggested to take lithium with meals to reduce nausea. Option B: To reduce thirst and maintain
normal fluid balance. Option C: An increase in salt intake increases lithium elimination, and a decrease in salt
intake decreases lithium elimination. Thus, the patient must maintain a balanced diet and salt intake. Option D:
Lithium must be taken on a regular basis, preferably at the same time daily. Patient should wait until the next
scheduled time to take the lithium if there is a missed dose, to prevent lithium toxicity.
Reference. Norman Keltner. Psychiatric Nursing. 5th edition. Page 258-259
56. A client with bipolar disorder, manic phase, who usually dresses conservatively, appears at breakfast with
brightly colored cheeks, wearing a miniskirt, sheer blouse, and designer boots. Which of the following actions
should the nurse take to deal with the client's attire?
a. Redirect the client to her room and help her put on her more customary clothing.
b. Allow her the freedom to wear what she prefers for now
c. Remind the client of the dress code and the consequences of violation
d. Tell the client what to wear and advise her that she has lost the privilege of choosing her wardrobe.
ANSWER: A
The nurse must protect the client from actions that will cause embarrassment when her condition improves.
Option B - Allowing her the freedom to wear what she prefers doesn't remove the client from the embarrassing
situation.
Option C and D - Reminding the client of the dress code and telling her what to wear offer chastisement rather
than guidance and support.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 326-328
57. Family members of a client with bipolar disorder tell the nurse that they are concerned that the client is
becoming manic. The nurse knows that the manic phase is marked by:
a. flight of ideas and inflated self-esteem.
b. increased sleep and greater distractibility.
c. decreased self-esteem and increased physical restlessness.
d. obsession with following rules and maintaining order.
ANSWER: A
The manic phase of bipolar disorder is characterized by recurrent episodes of a persistently euphoric and
expansive or irritable mood. This phase is diagnosed if the client has four of the following signs and symptoms for
at least 1 week: flight of ideas; inflated self-esteem; unusual talkativeness; increased social, occupational, or
sexual activity; physical restlessness; a decreased need for sleep; increased distractibility; and excessive
involvement in activities with a high potential for painful but unrecognized consequences. Obsession with
following rules and maintaining order characterizes obsessive-compulsive disorder.
58. A client in the manic phase of bipolar disorder constantly belittles other clients and demands special favors
from the nurses. Which nursing intervention would be most appropriate for this client?
a. Ask other clients and staff members to ignore the client's behavior.
b. Set limits with consequences for belittling or demanding behavior.
c. Offer the client an antianxiety drug when belittling or demanding behavior occurs.
d. Offer the client a variety of stimulating activities to distract him from belittling or making demands of others.
ANSWER: B
To protect others from a client who exhibits belittling and demanding behaviors, the nurse may need to set limits
with consequences for noncompliance. Asking others to ignore the client is likely to increase those behaviors.
Offering the client an antianxiety drug or stimulating activities provides no motivation for the client to change
problematic behaviors.
59. One day after being admitted with bipolar disorder, a client becomes verbally aggressive during a group
therapy session. Which response by the nurse would be therapeutic?
a. "You're behaving in an unacceptable manner, and you need to control yourself."
b. "If you continue to talk like that, no one will want to be around you."
c. "You're disturbing the other clients. I'll walk with you around the patio to help you release some of your
energy."
d. "You're scaring everyone in the group. Leave the room immediately."
ANSWER: C
This response shows that the nurse finds the client's behavior unacceptable, yet still regards the client as worthy
of help. The other options give the false impression that the client is in control of the behavior; the client hasn't
been in treatment long enough to control the behavior.
60. A client exhibits the following defining characteristics: denial of problems that are evident to others,
expressions of shame or guilt, perceptions of self as being unable to deal with events, and projection of blame or
responsibility for problems onto others. How would a nurse diagnose this client?
a. Anxiety
b. Chronic low self-esteem
c. Ineffective denial
d. Ineffective coping
ANSWER: B
The defining characteristics are those of chronic low self-esteem. The definition of this diagnosis is negative selfevaluation, along
with negative feelings about self or capabilities, which may be directly or indirectly expressed.
Anxiety, denial, and ineffective coping all have different sets of defining characteristics.
SITUATION: Depression is usually first identified in a primary-care setting, not in a mental health practitioner's
clinic. Moreover, it often assumes various disguises, which causes depression to be frequently underdiagnosed.
61. A young woman, appearing to be depressed, is brought to the emergency room. History revealed that the
woman lost her child a year ago from an accident. The initial nursing diagnosis is dysfunctional grieving. Which of
the following statements of the woman would support this diagnosis?
a. “I feel jealous of mothers who have toddlers”
b. “I haven’t been able to open the door and go into my baby’s room “
c. “I watch other toddlers and think about their play activities and I cry.”
d. “I often find myself thinking of how I could have prevented the death.
ANSWER: B
Option B indicates denial. This defense is adaptive as an initial reaction to loss but an extended, unsuccessful use
of denial is dysfunctional. A. This indicates acknowledgement of the loss. Expressing feelings openly is
acceptable. C. This indicates the stage of depression in the grieving process. D. Remembering both positive and
negative aspects of the deceased love one signals successful mourning
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 806-807
62. Which is the appropriate nursing diagnosis for client saying: “I’m no good; I can’t even take care of my
child”?
a. Ineffective individual coping related to loss.
b. Impaired verbal communication related to inadequate social skills.
c. Low self-esteem related to failure in role performance
d. Impaired social interaction related to repressed anger.
Answer: C
Low self-esteem related to failure in role performance
This indicates the client’s negative self evaluation. A sense of worthlessness may accompany depression. Options
A,B and D are not relevant. The cues do not indicate inability to use coping resources, decreased ability to
transmit/process symbols, nor insufficient quality of social exchange
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 365
63. Nurse Angel is caring for a depressed female client who has suicidal tendencies. When accompanying the
client to the restroom, Nurse Monet should:
a. Give her some time alone
c. Open the window for some fresh air
b. Give her space
d. Continue to observe her
ANSWER: D
The Nurse has a responsibility to observe continuously the acutely suicidal client. The Nurse should watch for
clues, such as communicating suicidal thoughts, and messages; hoarding medications and talking about death.
Reference: Videbeck, Sheila L. Psychiatric Mental Health Nursing, 2nd edition, Page 364-365
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 267
64. A 30-year-old sales manager tells the nurse, "I am thinking about a job change. I don't feel like I am living
up to my potential." Which of Maslow's developmental stages is the sales manager attempting to achieve?
a. Self-Actualization.
b. Loving and Belonging.
c. Basic Needs.
d. Safety and Security.
Answer: A
Self-actualization is the highest level of Maslow's development stages, which is an attempt to fulfill one's full
potential. Option B is identifying support systems. Option C is the first level of Maslow's developmental stages
and is the foundation upon which higher needs rest. Individuals who feel safe and secure (Option D) in their
environment perceive themselves as having physical safety and lack fear of harm.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 60
65. A client was admitted with a diagnosis of depression. The nurse knows that the most indicative characteristic
of depression is which of the following?
a. Grandiose ideation.
c. Suspiciousness of others.
b. Self-destructive thoughts.
d. A negative view of self and the future.
Answer: D
Negative self-image and feelings of hopelessness about the future (option D) are specific indicators for
depression. (Option A and/or C) occurs with paranoia or paranoid ideation. (Option B) may be seen in depressed
clients, but are not always present, so option D is a better answer than Option B.
Reference: Ann Isaacs. Mental Health and Psychiatric Nursing. 4th edition. Page 110-111
66. The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very
depressed. What is the most important intervention to implement during the first 48 hours after the client's
admission to the unit?
a. Monitor appetite and observe intake at meals.
c. Provide ongoing, supportive contact.
b. Maintain safety in the client's milieu.
d. Encourage participation in activities.
Answer: B
The most important reason for closely observing a depressed client immediately after admission is to maintain
safety (Option B), since suicide is a risk with depression. (Options A, C, and D) are all important interventions,
but safety is the priority.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 365
67. The nurse is planning the care for a 32-year-old male client with acute depression. Which nursing
intervention best helps the client deal with his depression?
a. Ensure that the client's day is filled with group activities.
b. Assist the client in exploring feelings of shame, anger, and guilt.
c. Allow the client to initiate and determine activities of daily living.
d. Encourage the client to explore the rationale for his depression.
Answer: B
Depression is associated with feelings of shame, anger, and guilt. Exploring such feelings is an important nursing
intervention for the depressed client (option B). If the client's day is filled with group activities (option A) he
might not have the opportunity to explore these feelings. Option C is a good intervention for the chronically
depressed client who exhibits vegetative signs of depression. Option D is essentially asking the client "why" he is
depressed--avoid "why’s" disguised as "rationale."
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 362-363
68. The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which
complaint related to the drug administration should the nurse expect this client to make?
a. My mouth feels like cotton.
c. This pill gives me diarrhea.
b. That stuff gives me indigestion.
d. My urine looks pink.
ANSWER: A
A dry mouth (Option A) is an anticholinergic effect that is an expected side effect of MAO inhibitors such as
phenelzine sulfate (Nardil). (options B, C, and D) are not expected side effects of this medication.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 123
SITUATION: Manic-depressive illness or bipolar disorder affects both men and women. Although it can start at
any age, it usually begins in late adolescence. Bipolar disorder is found among people of all ages, races, ethnic
groups, and social classes.
69. A 27-year-old female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic
phase. She is demanding and active. Which intervention should the nurse include in this client's care plan?
a .Schedule her to attend various group activities.
c .Encourage her to identify feelings of anger.
b .Reinforce her ability to make her own decisions.
d .Provide a structured environment with little stimuli.
Answer: D
Clients in the manic phase of a bipolar disorder require decreased stimuli and a structured environment. Plan
noncompetitive activities that can be carried out alone. Option A is contraindicated; stimuli should be reduced as
much as possible. Impulsive decision-making is characteristic of clients with bipolar disorder. Option : To prevent
future complications, the nurse should monitor these clients' decisions and assist them in the decision-making
process. Option C is more often associated with depression than with bipolar disorder.
Reference: Ann Isaacs. Psychiatric Mental Health Nursing. 4th edition. Page 114
70. A client who is being treated with lithium carbonate for manic depression develops diarrhea, vomiting, and
drowsiness. What action should the nurse take?
a. Notify the healthcare provider immediately and prepare for administration of an antidote.
b. Notify the healthcare provider of the symptoms prior to the next administration of the drug.
c. Record the symptoms as normal side effects and continue administration of the prescribed dosage.
d. Hold the medication and refuse to administer additional amounts of the drug.
Answer: B
Early side effects of lithium carbonate (occurring with serum lithium levels below 2.0 mEq per liter) generally
follow a progressive pattern beginning with diarrhea, vomiting, drowsiness, and muscular weakness. At higher
levels, ataxia, tinnitus, blurred vision, and large dilute urine output may occur. Option B is the best choice.
Although these are expected symptoms, the healthcare provider should be notified prior to the next
administration of the drug. Options A, C, and D would not reflect good nursing judgment.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 372-373
71. The nurse is conducting a class about the adverse reactions to a variety of drugs, such as lithium carbonate
(Eskalith), carbamazepine (tegretol), gabapentin (Neurontin) and valproic acid (Depakene). Which of the
following common adverse reactions should the nurse include in the class?
I. Nausea
III. Diarrhea
VI. Irritability
II. Restlessness
IV. Insomnia
V. Dyspepsia
a. I, II, III
b. IV, V, VI
c. I, III, V
d. All of the above
ANSWER: C
Lithium is an antimanic and antipsychotic drug used in the treatment of bipolar disorders. Carbamazepine
(tegretol) is an anticonvulsant used to treat absence seizures. It is also used investigationally in the treatment of
bipolar disorders, schizophrenia, and psychotic behavior with dementia. Gabapentin (Neurontin) is anticonvulsant
used in the treatment of seizures. It is also used investigationally for bipolar disorders. Valproic acid (Depakene)
is an anticonvulsant used in the treatment of seizures. Common adverse reactions for all of these drugs include
nausea, diarrhea and dyspepsia.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 116-118
72. The nurse reads on the initial history and physical assessment of a client who was prescribed anticonvulsants.
The nurse notes that there is neither diagnosis of a seizure disorder nor a report of treatment in a mental health
clinic. The nurse concludes that the client is taking the anticonvulsant drugs to treat which of the following
except?
a. Major depression
b. Bipolar disorder
c. Aggression
d. Anxiety disorder
ANSWER: A
Anticonvulsant drugs are being used investigationally in the treatment of Options B, C and D.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 116-118, 372-375
73. A nurse is instructing a hospitalized client about getting blood drawn the following day for lithium carbonate
(Eskalith) level. Which of the following instructions is important?
a. “Do not take your morning dose of lithium until your blood has been drawn”
b. “Do not eat anything in the morning before having your blood drawn”
c. “Do not take your evening dose of lithium tonight”
d. “Take your morning dose of lithium with a sip of water”
ANSWER: A
Lithium blood level is most accurate if the blood is drawn 12 hours after the last dose of drug. In the hospital
setting, nurses should withhold the morning dose of lithium until the serum sample is drawn to avoid falsely
elevated. Individuals who are at home should be instructed to have their blood drawn in the morning about 12
hours after their last dose and before they take their first dose of medication.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 116-117
74. A female manic patient taking lithium for maintenance suddenly develops constipation, bradycardia and cold
intolerance. The nurse suspects that the client developed which of the following?
a. Early signs of toxicity
b. Hypothyroidism
c. Hypoparathyroidism
d. Pseudoparkinsonism
ANSWER: B
Lithium may alter thyroid function, usually after 6 to 18 months of treatment. Thyroid dysfunction from lithium is
more common in women. During maintenance, TSH levels may be monitored. Nurses should observe for dry skin,
constipation, Bradycardia, hair loss, cold intolerance and other symptoms of hypothyroidism. Option A: early
signs of toxicity to lithium include severe diarrhea, vomiting, drowsiness, muscle weakness, and lack of
coordination. Option C: unrelated. Optin D: Pseudoparkinsonism results from antipsychotic use.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 117
75. A 35-year-old client with a diagnosis of bipolar disorder, mixed and borderline personality disorder was
brought to the Emergency Department after taking a handful of pills and calling Police Hotline. The nurse
overheard a staff member saying of the client, “Oh, here she comes again. If she was serious about committing
suicide, she’d have done it by now.” The nurse considers which of the following when preparing to see the client?
a. Clients with personality disorders rarely kill themselves.
b. People who talk about suicide or have a history of suicidal behavior are at serious risk of self-harm and each
event must be taken seriously.
c. The nurse should not reinforce manipulative behaviors, therefore the nursing assessment must be brief and
exploration of suicidal ideations must be kept to a minimum.
d. The nurse should anticipate that the client will be admitted directly to the inpatient unit.
Answer: B
Rationale: The majority of people who commit suicide communicate intent either verbally or nonverbally. All
expressions of suicidal intent must be taken seriously and each episode must be evaluated individually. Clients
with personality disorders (option A) are at greater risk of committing suicide than the general public. This client
is at serious risk of suicide and a complete assessment must be performed (option C). The client may or may not
be admitted to the inpatient unit (option D).
SITUATION: Nurses will come in contact with patients who have mood disorders when they present to clinics,
emergency rooms, on a medical floor of a hospital or a psychiatric ward.
76. The nurse would expect a client who is exhibiting the vegetative signs of depression to have:
a. Constipation and insomnia.
b. Hopelessness.
c. Suicidal ideation and a plan.
d. Helplessness.
ANSWER: A
Constipation and insomnia is the only answer choice that is physiological. The vegetative signs of depression are
physiological. Suicidal ideation and a plan, helplessness, and hopelessness are all psychological.
Reference: Kneisl. Contemporary Psychiatric Mental Health Nursing 2nd edition
77. The major difference between bipolar disorder and major depressive disorder is that in bipolar disorder there
is:
a. A mania component.
c. Suicidal ideation.
b. No history of depressive feelings.
d. Only one week of symptoms
ANSWER: A
A mania component is the defining feature of bipolar disorder. The client may or may not have suicidal ideation.
Bipolar disorder has both mania and depressive components. Bipolar disorder is not diagnosed with only one
week of symptoms.
Reference: Kneisl. Contemporary Psychiatric Mental Health Nursing 2nd edition
78. During a nurse-client interaction, an adolescent client with a major depressive disorder stated, "I was on the
swim team at school, but I don't enjoy swimming anymore so I quit." The client is describing:
a. Aphasia
b. Anhedonia
c. Antagonism
d. Anergia
ANSWER: B
Anhedonia describes the inability of the client to enjoy an activity that used to give pleasure and is a symptom of
depression. Anergia is a lack of energy. Aphasia is a lack of language abilities. Antagonism is being oppositional.
Reference: Kneisl. Contemporary Psychiatric Mental Health Nursing 2nd edition
79. A client with mania is demonstrating hypersexual behavior: blowing kisses to other clients, making
suggestive remarks, and removing some articles of clothing. Which of the following interventions is indicated at
this time?
a. Accompany the client to her room to get her dressed.
b. Put the client in seclusion for her own protection.
c. Tell other clients to ignore the behavior because it is harmless.
d. Tell the client that the behaviors have to stop right now.
ANSWER: A
During a manic episode, protection of the patient is a priority. It is during a manic episode that poor judgment
and impulsivity result in risk-taking behaviors that can have dire consequences for the patient and family.
Reference: Videbeck, S.L. Psychiatric Mental Health Nursing 4th Edition
80. The client with mania attempts to hit the nurse. Which of the following is the best response by the nurse?
a. “Do not swing at me again. If you cannot control yourself, we will help you.”
b. “If you do that one more time, you will be put in seclusion immediately.”
c. “Stop that. I didn't do anything to provoke an attack.”
d. “Why do you continue that kind of behavior? You know I won't let you do it.”
ANSWER: A
Setting limits tells the patient that you'll provide security and protection by refusing inappropriate and possibly
harmful requests. Set limits in a calm, clear, and self confident manner for the manic patient's demanding,
hyperactive, manipulative, and acting-out behaviors. Avoid leaving fill opening for the patient to test you of argue
with you.
Reference: Videbeck, S.L. Psychiatric Mental Health Nursing 4th Edition
81. A client with bipolar disorder is admitted to the psychiatric unit. The client is talking loudly, walking back and
forth rapidly, and exhibiting a short attention span. Which of the following would the nurse do first?
a. Decrease the client's environmental stimuli.
c. Introduce the client to other staff on the unit.
b. Give the client feedback about his behavior.
d. Tell the client about hospital rules and policies.
ANSWER: A
Limiting stimuli can be helpful in decreasing the client’s behavior. This allows for more of a self-control and
provides safety for the client and other clients in the unit. Other options will leave an opening for the patient to
argue with you.
Reference: Videbeck, S.L. Psychiatric Mental Health Nursing 4th Edition
82. The client has been taking the monoamine oxidase inhibitor (MAOI) phenelzine (Nardil), 10 mg bid. The
physician orders a selective serotonin reuptake inhibitor (SSRI), paroxetine (Paxil), 20 mg given every morning.
The nurse:
a. Gives the medication as ordered
b. Questions the physician about the order
c. Questions the dosage ordered
d. Asks the physician to order benztropine (Cogentin) for the side effects.
ANSWER: B
The nurse questions the physician about the order because the client who has been taking a MAOI such as
phenelzine must wait 14 days after stopping the MAOI before starting an SSRI such as paroxetine. Serotonin
syndrome, a potentially lethal consequence, can occur when combining an MAOI and an SSRI. Serotonin
syndrome is characterized by hyperreflexia, hyperthermia, myoclonus, and other symptoms similar to neuroleptic
malignant syndrome.
Option A - Giving the medication as ordered can result in serious adverse consequences, as described above.
Option C - The dosage is accurate.
Option D - Benztropine is not given with an SSRI; it is an antiparkinsonian agent usually ordered for the side
effects of antipsychotic medication.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 315-316
83. The nurse is administering atropine sulfate to a client about to undergo electroconvulsive therapy. Which
assessment indicates that the medication is effective?
a. The client's heart rate is 48 beats/minute
c. The client appears calm and relaxed
b. The client states that his mouth is dry
d. The client falls asleep.
ANSWER: B
Atropine sulfate is administered approximately 30 minutes before electroconvulsive therapy to reduce oral
secretions; therefore, the client's mouth would feel dry.
Option A - Atropine also blocks the vagal stimulation of the heart, causing a rise in heart rate (much higher than
48 beats/minute).
Option C and D - Atropine sulfate isn't given to make the client feel calm and relaxed nor does it induce sleep.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 316
84. Nurse Mian is documenting a care plan for a client who has undergone electroconvulsive therapy (ECT).
Which intervention should Nurse Mian include?
a. Monitoring the client's vital signs every hour for 4 hours
c. Encouraging early ambulation
b. Placing the client in Trendelenburg's position
d. Reorienting the client to time and place
ANSWER: D
Confusion and temporary memory loss are the most common adverse effects of electroconvulsive therapy. The
nurse should continually reorient the client to time and place as he wakes up from the procedure.
Option A - Following electroconvulsive therapy, the nurse should monitor the client's vital signs every 15 minutes
for the 1st hour.
Option B - The nurse should position the client on his side after the procedure to reduce the risk of aspiration.
Option C - The client should remain on bed rest until he's fully awake and oriented.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 316
85. After the nurse has taught the client who is being discharged on lithium (Eskalith) about the drug, which of
the following client statements would indicate that the teaching has been successful?
a. "I need to restrict eating any foods that contain salt."
b. "If I forget a dose, I can double the dose the next time I take it."
c. "I'll call my doctor right away for any vomiting, severe hand tremors, or muscle weakness."
d. "I should increase my fluid intake to five to six 8-ounce glasses of water each day."
ANSWER: C
A client receiving lithium is at risk for toxicity, evidenced by diarrhea, vomiting, ataxia, tremor, drowsiness, lack
of coordination, or muscle weakness. Thus, the client's statement about notifying the doctor about possible signs
of lithium toxicity reflects accurate knowledge about the drug and successful teaching.
Option A - The client needs to maintain a normal salt intake because eliminating salt from the diet can lead to
lithium toxicity.
Option B - When a dose is skipped or missed, doubling the dose at the next scheduled time increases the client's
chance for lithium toxicity.
Option D - Drinking ten to twelve 8-ounce glasses of water per day is recommended for the client receiving
lithium to prevent toxicity.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 326-329
86. A client reports no improvement in mood since beginning a regimen of 15 mg of tranylcypromine (Parnate)
twice per day 1 week ago. Which of the following is the best nursing action?
a. Say to the client, "The medication may need up to 4 weeks to take effect."
b. Say to the client, "You should feel the effects any day now."
c. Consult with the physician about a dosage adjustment.
d. Consult with the physician about a change of medication.
ANSWER: A
MAO inhibitors, such as tranylcypromine, may take up to 4 weeks before improving the client's mood. Telling the
client he will feel better soon is a vague promise that may create unrealistic expectations in the client. Consulting
the physician is premature.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 315-316
87. The nurse assesses a client who complains of insomnia, fatigue, and depression every day. “It has been like
this since I was a child,” said the client. The nurse suspects the client has dysthymic mood disorder, because to
be diagnosed with dysthymic mood disorder, a person must experience which of the following symptoms?
a. Insomnia for several years--more days having problems sleeping than not having problems sleeping
b. The triad of insomnia, fatigue, and depression over several continuous years
c. Depressed mood for at least 2 years, more days depressed than not depressed
d. Episodes of depression over time with no evidence of suicidal ideation
ANSWER: C
To be diagnosed with a dysthymic mood disorder, a person must experience a depressed mood for at least 2
years. The individual feels depressed nearly all of the time. The depressed mood is experienced most of the day,
for more days than not. A person with dysthymic disorder must also have at least two of the following symptoms:
appetite disturbance, sleep disturbance, fatigue, low self-esteem, poor concentration or difficulty making
decisions, and feelings of hopelessness.
Reference: Noreen Cavan Frisch. Psychiatric Mental Health Nursing 4th edition
88. During a widows and widowers’ support group 18 months after the death of her husband, an elderly woman
stated, “I still miss my husband, but for the first time since my husband died, I’m going to take a vacation with
my church group.” This statement suggests that this widow has done which of the following?
a. Not completed her “grief work” successfully
c. Reached the recovery stage of grief
b. Not completed the initial shock/disbelief stage
d. Completed the reality stage of bereavement
ANSWER: C
The woman’s statement indicates that she has reached the recovery stage, the final stage. She is able to
integrate the loss into the reality of her life and begin to live again. The individual’s progress has been facilitated
by the caring demonstrated in the widows and widowers’ support group over the past 18 months since the death
of her husband.
Reference: Noreen Cavan Frisch. Psychiatric Mental Health Nursing 4th edition
89. Nurse Sisa is assigned to care for a recently admitted client who has attempted suicide. Nurse Sisa should
implement which of the following actions?
a. Express trust that the client won't cause self-harm while in the facility.
b. Respect the client's privacy by not searching any belongings.
c. Remind all staff members to check on the client frequently.
d. Search the client's belongings and room carefully for items that could be used to attempt suicide.
ANSWER: D
Because a client who has attempted suicide could try again, the nurse should search the client's belongings and
room to remove any items that could be used in another suicide attempt. Expressing trust that the client won't
cause self-harm may increase guilt and pain if the client can't live up to that trust. The nurse should search the
client's belongings because the need to maintain a safe environment supersedes the client's right to privacy.
Although frequent checks by staff members are helpful, they aren't enough because the client may attempt
suicide between checks.
90. The client is transferred to the psychiatric inpatient unit of a general hospital from the surgical ICU after
being treated for a self-inflicted gunshot wound. The nurse schedules time to meet with the client on a one-toone basis with which of
the following goals in mind?
a. The client will explore current life events that led to the suicide attempt.
b. The client will initiate contact with the nurse spontaneously.
c. The client will identify past suicidal ideations and behavior.
d. The client will begin group therapy as soon as he is able to ambulate and remain seated for 50 minutes.
Answer: A
Rationale: A priority goal for the client, once safety has been assured, is to explore life events leading to the
decision to die. This can then be followed by reviewing current feelings in the hopes that the client will now want
to live. The other goals (options B, C, and D) are not relevant to the client’s current needs.
91. A client admitted to the psychiatric inpatient unit following expressed suicidal ideations tells the nurse the
next day that she feels fine, is at peace, and wants to go home now. The nurse understands that the client:
a. Has resolved her feelings and is no longer at risk for self-harm.
b. Is probably ready to be discharged to home since the suicidal intent has been resolved.
c. Remains at risk, may have sufficient psychic energy to act out on the suicidal ideation, and requires further
assessment.
d. Has reached a realistic self-appraisal of the serious nature of her suicidal intentions.
Answer: C
Rationale: People who have completed suicide frequently showed an improvement in mood and energy prior to
their deaths. Improved mood and energy may mean the client has resolved ambivalent feelings about suicide and
has decided to kill him- or herself.
92. The priority nursing diagnosis for a client with suicidal ideations and intent is:
a. Risk for violence, self-directed.
b. Ineffective individual coping.
c. Hopelessness.
d. Defensive
coping
Answer: A
Rationale: The first priority in caring for the client with suicidal ideation is maintaining safety. Ineffective
individual coping (option B), hopelessness (option C), and defensive coping (option D) are appropriate only after
safety has been assured.
93. A female client is placed on one-to-one observation, and as the nurse follows her into the bathroom, she
objects strongly, yelling, “I’m sick of being followed around and watched like a small child who can’t be trusted.”
The best response for the nurse would be:
a. “I understand you are angry, but I must be able to see you at all times to make sure you are safe.”
b. “Stop yelling at me! I can’t change the rules for clients who talk about suicide as you have done.”
c. “Well, you are better; I’ll wait outside the bathroom and you can close the door until you are finished.”
d. “You should stop being angry and uncooperative and focus on happy things.”
Answer: A
Rationale: Acknowledging the client’s feelings of frustration and reaffirming the need for safety is the priority.
Telling the client to stop yelling (option B) and telling the client to stop being angry (option D) ignore and
discount the client’s feelings. The client must be observed at all times to ensure her safety (option C).
94. A suicidal client with low self-esteem seems less lethargic today and agrees to participate in an occupational
therapy program. To help make the session most successful, the nurse should do which of the following?
a. Introduce the client to wood carving; show/tell him how to safely use the pointed carving and burning tools.
b. Stay away from the client in occupational therapy so that he is free to express himself.
c. Teach the client to make a macrame belt from long rope and encourage him to work on it later in his room.
d. Structure his activity to help him complete one simple task, such as painting a picture.
Answer: D
Rationale: A client who is just regaining his or her energy should be encouraged to do simple tasks, which will
also promote the client’s self-esteem. Suicidal clients are most at danger when they are feeling better and
regaining their energy. Introducing the client to wood carving (option A) and making a belt from rope (option C)
places the client at risk for self-harm. The nurse should encourage the client participate in the occupational
therapy for self-expression (option B).
95. A client has recently been admitted for depression and suicidal ideations with a plan to hang himself. The
client most at risk for attempting suicide when:
a. He is mute and unlikely to tell anyone.
c. His family goes on vacation.
b. He is ready to go home and afraid of leaving the hospital.
d. He begins to demonstrate improvement.
Answer: D
Rationale: Suicidal clients are at most risk when they begin to demonstrate improvement and have the energy to
carry out suicide. A mute client who is not willing to share with others (option A) is at risk for suicide but may be
placed on constant observation. Being afraid to go home (option B) may be a positive sign that the client is
aware of his dangerousness to self. Vacation is a stressful time and being left alone (option C) would place the
client at risk; however, it is well documented that clients are at greatest risk when showing signs of
improvement.
96. When interviewing a potentially violent or aggressive client, which of the following environmental factors is
most important?
a. The interview should take place in a private area to reduce external stimuli.
b. Care should be taken to make sure that other staffs do not interrupt.
c. Restraint devices should be in full view of the patient to reinforce consequences for behavior.
d. The client should be told that violent behavior will not be tolerated and violence would get him in trouble.
Answer: A
Rationale: The nurse should ensure that the interview be conducted in a private and quiet area. Interruption
should be kept to a minimum (option B), but may not be possible to prevent. Intimidation of the client (options C
and D) is inappropriate.
97. The nurse selects a diagnosis of “Ineffective individual coping related to feelings of anger, suicide, and
hopelessness.” Which of the following expected outcomes is the most appropriate for this nursing diagnosis? The
client will:
a. Deny feelings of hopelessness, anger, and suicide.
c. Voice no complaints.
b. Demonstrate a joyful and cheerful mood.
d. Share angry, suicidal feelings with the nurse.
Answer: D
Rationale: Having clients share their anger and suicidal feelings is critical for their recovery and in coping.
Denying feelings of hopelessness, anger, and suicide (option A) is not therapeutic. It is not always realistic for the
outcome of care to be joyful and cheerful mood (option B). Voicing no complaints (option C) does not indicate
whether the client is coping or not.
98. The nurse’s most important priority in caring for a client with a high suicide risk is to:
a. Administer tranquilizers to make the client less suicidal.
b. Monitor the client’s location and behavior constantly.
c. Change the subject whenever the client mentions suicide.
d. Allow client the time alone to reflect on feelings.
Answer: B
Rationale: Ensuring the client’s safety by placing him or her on constant observation is of highest priority. A
tranquilizer (option A) may decrease the client’s stress level, but may also disinhibit the client and make him or
her more at risk for suicide. Changing the subject (option C) is a nontherapeutic technique and is not advised.
The client should not be left alone (option D); safety is a priority.
99. Clients with which diagnosis would be at lowest risk for suicide?
a. Major depression
b. Obsessive-compulsive behavior
c. Schizophrenia
d. Chemical dependency
Answer: B
Rationale: Clients who are obsessive-compulsive usually have a difficult time concentrating enough to commit
suicide. Clients with major depression (option A), schizophrenia (option C), and chemical dependency (option D)
are at higher risk for suicidal behavior.
100. Which of the following questions would not be appropriate to ask a client while taking a comprehensive
history to assess the client’s potential for violence or aggression?
a. “What is the closest you have come to being violent?”
c. “When were you sexually or physically abused?”
b. “Have you ever been arrested?”
d. “Do you worry about being violent?”
Answer: C
Rationale: Not all clients who are violent or aggressive have been sexually or physically abused. Asking the
question as if the client were sexually or physically abused may cause them to become aggressive. A better way
of asking the question would be, “Have you ever been sexually or physically abused?” Options A, B, and D are
appropriate questions to ask a potentially violent or aggressive client.
MENTAL HEALTH AND PSYCHIATRIC NURSING
OVERVIEW OF PSYCHIATRIC NURSING
SITUATION: Mental health care has undergone profound changes in the past 50 years. Today, people with
mental illness received treatment in varied healthcare settings.
1. You are working with a group of clients who ask you to explain what is meant by mental health. You would
explain that there are many definitions, but the broadest agreement is that a key component is the ability to:
a. Amass material property
c. Get one's needs met without delay
b. Be optimistic in all situations
d. Respond to stress effectively
ANSWER: D
Key components of mental health that have broad acceptance include the ability to respond to stress effectively;
the capacity to tolerate anxiety, stress, and frustration; to delay gratification of needs; and the capacity to
realistically and objectively appraise events and situations in one's world.
Reference: Antai-Otong. Psychiatric Nursing: Biologic and Behavioral Concepts 2nd edition
2. The creation of asylums during the 1800s was meant to:
a. Improve treatment of mental disorders
c. Punish mentally ill persons believed to be possessed
b. Provide food and shelter for the mentally ill
d. Remove dangerous mentally ill persons from the community
ANSWER: B
In the 1790s, a period of enlightenment concerning persons with mental illness began. Phillippe Pinel in France
and William Tukes in England formulated the concept of asylum as a safe refuge or haven offering protection at
institutions where people had been whipped, beaten, and starved just because they were mentally ill. In the
United States, Dorothea Dix (1802–1887) began a crusade to reform the treatment of mental illness after a visit
to Tukes’ institution in England. She was instrumental in opening 32 state hospitals that offered asylum to the
suffering. Dix believed that society was obligated to those who were mentally ill and promoted adequate shelter,
nutritious food, and warm clothing.
Reference: Videbeck. Psychiatric Mental Health Nursing 4th edition
3. The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) classifies
mental illness based on which of the following?
a. Descriptive symptomatology
c. Research-based scientific studies
b. Qualitative research methods
d. Subjective symptomatology
ANSWER: A
The DSM-IV-TR has three purposes: To provide a standardized nomenclature and language for all mental health
professionals; To present defining characteristics or symptoms that differentiate specific diagnoses; To assist in
identifying the underlying causes of disorders.
Reference: Videbeck. Psychiatric Mental Health Nursing 4th edition
4. Nurse Isabel is a psychiatric nurse assessing a client on Axis V of the DSM-IV-TR. She is trying to determine:
a. The presenting clinical problem
c. The client's highest level of functioning in the past year
b. Physical disorders and conditions
d. The severity of psychosocial stressors the client is experiencing
ANSWER: C
Axis V is the highest level of adaptive functioning in the past year. Physical disorders and conditions would be
Axis III, and severity of psychosocial stressors would be Axis IV.
Reference: Antai-Otong. Psychiatric Nursing: Biologic and Behavioral Concepts 2nd edition
5. The following had major contributions to the field of psychiatric nursing. Who among the following is the first
American psychiatric nurse?
a. Linda Richards
b. Dorothea Dix
c. Clara Barton
d. Hildegard Peplau
ANSWER: A
Linda Richards, the first American psychiatric nurse, was a graduate of the New England Hospital for Women.
Option B: Dorothea Dix, one of the first reformer and instrumental to the development of the concept of asylum.
Option C: established American Red Cross. Option D: First Psychiatric Nursing Theorists
Reference:Norman Keltner. Psychiatric Nursing. 5th edition. Page 4-13
SITUATION: A person’s behavior can provide cues to his or he mental health. Because each person can have
different view or interpretation of behavior, the determination of mental health may be difficult.
6. During shift report, a nurse describes a client as "crazy." Which approach by the nurse would be best?
a. Ask the staff what terminology they wish to use.
c. Suggest that staff use the term "mentally ill."
b. Say nothing.
d. Role model using the term "nervous breakdown."
ANSWER: C
The nurse should suggest that staff use the term "mentally ill," thus reinforcing that the client has an illness. The
term "nervous breakdown" is too general and nonspecific for clinical usage. Saying nothing or asking staff what
terminology to use is not implementing the client-advocate role of the professional nurse.
Reference: Kneisl C.R. Contemporary Psychiatri-Mental Health Nursing 2nd edition
7. Nurse Hannah is sharing client assessment data with the multidisciplinary health care team. Which comment
by Nurse Hannah is irrelevant and indicates a misunderstanding of the concept of a mental disorder?
a. "The client reports a loss of interest in usual pleasurable activities and commitments."
b. "The client denies thoughts of harming self or others."
c. "The client has some very inappropriate religious ideas and spiritual beliefs."
d. "The client reports significant emotional distress about the current situation."
ANSWER: C
Deviant religious beliefs and behavior are not generally labeled as mental disorders unless the deviance is a
symptom of dysfunction. Thoughts of harming self or others, emotional distress, and a loss of interest in usual
pleasurable activities and commitments are relevant and meet the generally accepted definition of a mental
disorder.
Reference: Kneisl C.R. Contemporary Psychiatri-Mental Health Nursing 2nd edition
8. The nursing student verbalizes to the psychiatric nurse that normal people do not have mental disorders.
Which approach by the nurse would be best?
a. Alert the clinical instructor of the nursing student's remark.
b. Instruct that anyone can have a mental health problem.
c. Ignore the comment; the student has no responsibility in this situation.
d. Refer the nursing student back to the psychiatric orientation materials.
ANSWER: B
The nurse should instruct that given the right circumstances, anyone can have a mental health problem or
disorder. The nursing student’s ability to be therapeutic with clients may be decreased if misinformation is not
corrected. Referring the student back to the orientation materials, alerting the clinical instructor, and ignoring the
comment do not address the situation directly. The nurse has an opportunity to be a positive role model and
teacher and promote therapeutic care.
Reference: Kneisl C.R. Contemporary Psychiatri-Mental Health Nursing 2nd edition
9. Nurse Isabel is teaching the client regarding the concept of mental disorders. In instructing the client, what
areas should be covered in the explanation of what impacts the determination of a mental disorder?
1. Culture
3. Biochemistry
5. Brain structure
2. Mother-child interactions
4. Social conditions
a. 1 and 3
b. 1, 2, 3, 4
c. All except 2
d. All of the above
ANSWER: C
1. Behavior may be considered part of a mental disorder in one culture, but perfectly normal and acceptable in
another.
2. While family interactions are important in mental health, current theory and research emphasize a more
biological and societal definition.
3. Research has shown that brain chemicals and processes are frequently altered in mental disorders.
4. The appropriateness of behavior is judged as plausible or not plausible according to a set of social, ethical, and
legal rules that define the limits of appropriate behavior and reality.
5. Contemporary diagnostic testing has demonstrated some structural differences in persons who have mental
disorders.
Reference: Kneisl C.R. Contemporary Psychiatri-Mental Health Nursing 2nd edition
10. Nurse Daniel is told that the client most likely has the diagnosis of obsessive-compulsive disorder. Nurse
Daniel is not sure of the assessment data and behaviors that accompany this disorder. Which action would be
most appropriate for the nurse to take?
a. Ask the primary health provider to identify needed subjective and objective assessment data.
b. Consult the Diagnostic and Statistical Manual of Mental Disorders for diagnostic criteria.
c. Document all subjective and objective data provided by the client.
d. Research obsessive-compulsive disorder in the medical dictionary.
ANSWER: B
The Diagnostic and Statistical Manual of Mental Disorders provides diagnostic criteria that all members of the
health care team will use in the diagnosis process and will serve as a resource for assessment and analysis of
data. While communication with the primary care provider is appropriate, knowledge of the DSM is expected in a
graduate nurse and this choice does not reflect an application of basic knowledge. A medical dictionary is not
specific enough for diagnostic purposes. Documentation of all subjective and objective data is not appropriate and
will confuse relevant from irrelevant data.
Reference: Kneisl C.R. Contemporary Psychiatri-Mental Health Nursing 2nd edition
11. The nurse receives the shift report on a newly admitted client with a history of drug abuse and prostitution.
Prior to hospitalization, the client’s parental rights were terminated. Which of the following actions best
demonstrates the nurse’s ability to enhance self-knowledge?
a. The nurse will review the current literature pertaining to drug addiction.
b. The nurse will examine his or her own feelings with regard to this client.
c. The nurse will ignore the challenge to his or her self-view.
d. The nurse will ask for guidance from the charge nurse.
ANSWER: B
Examining one's own feelings regarding a client who engages in behaviors that are outside the nurse's behavior
norms promotes self-awareness and acceptance of deviance, which then allows the nurse to respond with
compassion and maintain empathy when meeting the client for the first time. Asking for guidance or reviewing
the literature before examining one's feelings indicates that the nurse is unaware or uncomfortable with feelings
and relies on others for guidance. Ignoring how one's self-view might be challenged by a patient situation
indicates the nurse is not able to confront how the diversity of client behaviors or experiences impacts the quality
and nature of the nurse's relationships with others.
Reference: Kneisl C.R. Contemporary Psychiatri-Mental Health Nursing 2nd edition
12. Which statement about contemporary mental health nursing practice is accurate?
a. There is one approved theoretical framework for psychiatric nursing practice.
b. Psychiatric nursing has yet to be recognized as a core mental health discipline.
c. Contemporary practice of psychiatric nursing is primarily focused on inpatient care.
d. The psychiatric nursing client may be an individual, family, group, organization, or community.
Answer: D
Mental health nursing is not only concerned with one-on-one interactions. Psychiatric stressors can impact and be
reflected in the overall direction, activities, and responses involving families, groups, and entire communities.
Options A, B, and C are incorrect statements about the status of mental health nursing.
Reference: Shives. Psychiatric Mental health Nursing. 7th edition. Page 7
13. One of the major contributions of the DSM was to:
a. officially recognize psychoanalytic theories as the primary etiology of all psychiatric disorders
b. indicate which psychiatric disorders have a neurophysiological basis and which have a psychoanalytic basis
c. officially recognize neurophysiological theories as the primary etiology of all psychiatric disorders
d. describe the phenomena of mental disorder without taking sides in the controversies of causation
ANSWER: D
A very important advantage of the DSM is the avoidance of controversies about what causes psychiatric
conditions. Much of the American and British psychiatry in the middle 20th century had been dominated by
psychoanalysis, and psychoanalytic theories of etiology were complex and rooted in subjective interpretations of
reported memories, experiences, and dreams. The neutrality of the DSM opened the way both for the widespread
acceptance of the DSM and for new, increasingly “biological” approaches to the understanding of mental illness.
Reference: Cavan Frisch. Psychiatric Mental Health Nursing 4th edition
SITUATION: Many theories attempt to explain human behaviors, health and mental illnesses. Each theory
suggests how normal development occurs based on the theorist’s beliefs, assumptions and view of the world. The
following questions refer to this.
14. A client begins to take stock of his life and look to the future. The nurse assesses that this client is in which
of Erikson's developmental stages?
a. Identity vs. role confusion
b. Industry vs. inferiority
c. Integrity vs. despair
d. Generativity vs. stagnation
ANSWER: C
A variety of disciplines still use Erikson’s eight psychosocial stages of development. In his view, psychosocial
growth occurs in sequential phases and each stage is dependent on completion of the previous stage and life
task.
Reference: Videbeck. Psychiatric Mental Health Nursing 4th edition
15. Psychoanalytic theory is based on Freud's ideas about personality. One basic assumption is:
a. All behavior has meaning.
c. Self-awareness is the key to understanding.
b. Human behavior is mostly unconscious.
d. Libido is not the driving force of behavior.
ANSWER: A
Psychoanalytic theory supports the notion that all human behavior is caused and can be explained (deterministic
theory). Freud believed that repressed (driven from conscious awareness) sexual impulses and desires motivated
much human behavior. Option B: Freud believed that behavior is motivated by subconscious thoughts and
feelings. Option C: Dream analysis, a primary method used in psychoanalysis, involves discussing a client’s
dreams to discover their true meaning and significance. Option D: Freud’s based his theory of childhood
development on the belief that sexual energy, termed libido, was the driving force of human behavior.
Reference: Videbeck. Psychiatric Mental Health Nursing 4th edition
16. Which approach to therapy is most effective when planning for a client with negative thinking?
a. Behavior modification
b. Client-centered therapy
c. Cognitive therapy
d. Reality therapy
ANSWER: C
Many existential therapists use cognitive therapy, which focuses on immediate thought processing— how a
person perceives or interprets his or her experience and determines how he or she feels and behaves. For
example, if a person interprets a situation as dangerous, he or she experiences anxiety and tries to escape. Basic
emotions of sadness, elation, anxiety, and anger are reactions to perceptions of loss, gain, danger, and
wrongdoing by others
Reference: Videbeck. Psychiatric Mental Health Nursing 4th edition
17. Which of the following is a major developmental task of middle adulthood?
a. Developing intimacy
b. Learning to manage conflict
c. Being productive
d. Resolving the past
ANSWER: C
Being creative and productive; establishing the next generation is the developmental task of middle adulthood.
Option A: Young adult. Option B: Pre-school. Option D: Old adult.
Reference: Videbeck. Psychiatric Mental Health Nursing 4th edition
SITUATION: Mental health care has undergone profound changes in the past 50 years. Today, people with
mental illness received treatment in variety of settings.
18. Which of the following is the nurse’s major basic function in psychiatric nursing?
a. Plan activity programs for client
b. Maintain a therapeutic environment
c. Understand various types of family therapy and psychological tests and how to interpret them.
d. Advance the science of psychiatry by initiating research and gathering data for current statistics on emotional illness.
ANSWER: B
Answer A, is mainly the function of a recreational occupational therapist, although nurses participate. Answer C is
usually filled by psychologists and social workers, and answer D is carried out primarily by psychologists or
statisticians, although nurses are involved. “Maintenance of a therapeutic environment” fits more readily into a
nursing role by virtue of the number of hours per day a nurse spends with the clients on a unit, in comparison
with the number spent by other professionals.
Reference: Videbeck. Psychiatric Mental Health Nursing. 3rd edition. Page 78
19. Who among the following is the first person to coin the term schizophrenia?
a. Emil Kraeplin
b. Eugene Bleuler
c. Sigmund Freud
d. William Tuke
ANSWER: B
Option A: Developed the classification of mental illness , Option C: Emphasized the importance of early life
experiences in shaping mental health, Option D: William Tuke: established York Retreat (1796), a private facility
that ensures moral treatment of the mentally ill.
Reference:Norman Keltner. Psychiatric Nursing. 5th edition. Pages 3-5
20. The following had major contributions to the field of psychiatric nursing. Who among the following is the first
American psychiatric nurse?
a. Linda Richards
b. Dorothea Dix
c. Clara Barton
d. Hildegard Peplau
ANSWER: A
Linda Richards, the first American psychiatric nurse, was a graduate of the New England Hospital for Women.
Option B: Dorothea Dix, one of the first reformer and instrumental to the development of the concept of asylum.
Option C: established American Red Cross. Option D: First Psychiatric Nursing Theorists
Reference:Norman Keltner. Psychiatric Nursing. 5th edition. Page 4-13
21. One of the most effective approaches to community based treatment for people with mental illness is
Assertive Community Treatment. All of the following are characteristics of ACT except:
a. Services are provided in the home or community
c. There are no time limitations on ACT services
b. Services are provided by the client’s case manager
d. All needed support systems are involved in ACT
ANSWER: B
For Case management approach, case managers follow the client from admission to discharge and serve as a
liaison between the client and community. Case managers works with clients on broad range of issues, from
accessing needed medical and psychiatric services to carrying out daily tasks.
Option A: Act programs provide most services directly rather than relying on referrals to other programs or
agencies and they implement the services in the client’s home or communities.
Option C: ACT programs also make a long term commitment to clients, providing services for as long as the need
persists and with no time constraints.
Option D: Involves all needed support systems for holistic treatment of the client.
Reference: Videbeck. Psychiatric Mental Health Nursing. 3rd edition. Page 71-76.
22. What is the nurse's most important role in caring for a client with a mental health disorder?
a. To offer advice
c. To establish trust and rapport
b. To know how to solve the client's problems
d. To set limits with the client
ANSWER: C
It's extremely important that the nurse establish trust and rapport. The nurse shouldn't offer advice. Instead, she
should help the client develop the coping mechanisms necessary to solve his own problems. Setting limits is also
important but not as important as developing trust and rapport.
Reference: Videbeck, S. L. (2004) Psychiatric Mental Health Nursing. 2nd edition. Lippincott Williams and Wilkins.
91
23. Which of the following theorists described the four levels of anxiety?
a. Carl Rogers
b. Erik Erikson
c. Hildegard Peplau
d. Sigmund Freud
ANSWER: C
Hildegard Peplau was a nursing theorist and clinician who developed the concept of the therapeutic nurse-patient
relationship which includes four phases (orientation, identification, exploitation and resolution and described the
four levels of anxiety which served as the foundation for working with clients with anxiety in a variety of contexts.
Carl Rogers – Client centered therapy (focus is on the role of the client and not the therapist)
Erik Erikson – Psychosocial stages of development
Sigmund Freud – Psychoanalytic theories, dream analysis, personality components, ego defense mechanisms,
psychosexual development
Reference: Videbeck, S. L. (2004) Psychiatric Mental Health Nursing. 2nd edition. Lippincott Williams and Wilkins.
58
24. During an assessment of a client the nurse finds that the client is trembling and restless, the client’s blood
pressure and pulse are elevated and the client is complaining of dry mouth, shortness of breath, inability to relax,
lose of appetite, and an upset stomach. What is the client’s level of anxiety?
a. Mild
b. Moderate
c. Severe
d. Panic
ANSWER: C
These are signs of the “fight-or-flight” response that occur at the severe level of anxiety. Mild anxiety is
associated with the tension of everyday life; the person is alert, the perceptual field is increased, and learning is
facilitated. In moderate anxiety, the perceptual field is narrowed, and low-level sympathetic arousal occurs. Panic
anxiety is associated with dread and terror, and physiological arousal interferes with motor activities.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 270
25. Which of the following actions should a nurse take during the pre-orientation phase of the nurse-patient
relationship?
a. Determining if the patient’s problems result from stressors
b. Establishing boundaries for the patient and the nurse
c. Exploring personal feelings regarding the care of the mental health patient
d. Identifying goals and strategies
ANSWER: C
Before meeting the client, the nurse has to consider his or her personal strengths and limitation while working
with this client. The nurse must also examine preconceptions about the client. This phase is a time for selfassessment. The
orientation phase begins when the nurse and the client meets and ends when the client begins
to identify problems to examine. During this phase, the nurse establishes the trust, roles, purpose of meeting and
identifies the client’s problems, clarifies expectations and sets boundaries.
Reference: Videbeck, S. L. (2004) Psychiatric Mental Health Nursing. 2nd edition. Lippincott Williams and Wilkins.
97
26. When assessing a client's level of stress caused by significant life events, which of the following would the
nurse use?
a. Holmes and Rahe's theory
c. The general systems theory
b. Selye's general adaptation syndrome theory
d. Lazarus's theory
ANSWER: A
Holmes and Rahe's theory suggests that all life events, whether positive or negative, cause stress. Holmes and
Rahe have created a readjustment scale that ranks life events according to how much stress they cause. Selye's
general adaptation syndrome theory explains a person's organized response to stress in three stages. The
general systems theory takes a holistic view of the stress response, recognizing both internal and external stimuli
affecting the person's health. Lazarus's theory suggests that the stress response occurs in three stages but it
views each stage as a conscious evaluation of the stimulus, not an automatic reaction.
27. A client is brought to the facility in an agitated state and is admitted to the psychiatric unit for observation
and treatment. While putting personal items away, the client talks rapidly and folds and unfolds garments several
times. The client can't seem to settle down. Which nursing diagnosis is most applicable at this time?
a. Disturbed personal identity
c. Compromised family coping
b. Anxiety
d. Powerlessness
ANSWER: B
Anxiety is the most applicable nursing diagnosis at this time because the client's behavior mimics some of the
objective signs of anxiety, which include restlessness, irritability, rapid speech, inability to complete tasks, and
verbal expressions of tension. The other options would be premature diagnoses because the nurse hasn't had an
opportunity to complete a thorough nursing assessment.
28. As infants in our society become toddlers and begin to experience mobility and autonomy, the greatest
stressor in their lives is usually:
a. Playmates
b. Limit setting
c. Family meals
d. Being babysat
ANSWER: B
As the child becomes mobile and autonomous, stress arises from limit setting, early discipline, and prolonged
separations from primary caregivers.
Reference: Antai-Otong. Psychiatric Nursing: Biologic and Behavioral Concepts 2nd edition
29. Assertive behavior involves:
a. Saying what is on one’s mind at the expense of others
b. Expressing an air of superiority
c. Avoiding unpleasant situations and circumstances
d. Standing up for one’s rights while respecting the rights of others
ANSWER: D
The basic element of assertive behavior includes the ability to express feelings and thoughts while respecting the
rights of others. Saying what is on one’s mind at the expense of others and expressing an air of superiority
describe aggressive behavior. Avoiding unpleasant situations and circumstances describes passive behavior.
Reference: Boyd. M.A. Psychiatric Nursing: Contemporary Practice. 3rd edition Page 809
30. Which action demonstrates the role of the psychiatric nurse in primary prevention?
a. Handling crisis intervention in an outpatient setting
c. Conducting a postdischarge support group
b. Visiting a client’s home to discuss medication management
d. Providing sexual education classes for adolescents
ANSWER: D
The psychiatric nurse participates in primary, secondary, and tertiary prevention activities. Primary prevention
includes education programs that promote mental health and prevent future psychiatric episodes such as sexual
education classes for adolescents. Secondary prevention involves treatment to reduce psychiatric problems (for
example, handling crisis intervention in an outpatient setting, administering and supervising medication
regimens, and participating in the therapeutic milieu). Tertiary prevention involves helping clients who are
recovering from psychiatric illness; activities directed toward providing aftercare and rehabilitation are part of this
role. Conducting a postdischarge support group is a tertiary prevention activity.
Reference: Boyd. M.A. Psychiatric Nursing: Contemporary Practice. 3rd edition Page 32
31. Which of the following activities by psychiatric nurses is the best example of secondary prevention?
a. Giving immunizations at a clinic for 2 year olds
b. Teaching teenagers about the problems of alcohol abuse
c. Working with a terminally ill client in the hospice program
d. Implementing measures that reduce symptoms of mental illness
ANSWER: D
Secondary prevention is the stage in which measures are used to reduce symptoms of a disease process.
Immunizations and teaching about the problems of alcohol abuse are primary prevention measures. Hospice care
is an example of tertiary prevention.
Reference: Antai-Otong. Psychiatric Nursing: Biologic and Behavioral Concepts 2nd edition
32. Which of the following statements if made by a patient who has terminal cancer demonstrates the stage of
bargaining as described in the theory of death and dying?
a. I know I am going to get better
c. I do not understand why this is happening to me
b. I have to put my financial affairs in order
d. Please let me live until the graduation of my grand daughter
ANSWER: D
Elizabeth Kubler Ross described the 5 stage of grieving. This is an example of a client in the bargaining stage. In
this stage, the client seeks to bargain to avoid loss. The client may express guilt or fear of punishment for the
past sins either real or imagined. In this stage, the nurse should listen attentively and encourage the client to
talk to relieve guilt and irrational fear. Options c and a is denial, option cb is acceptance.
SITUATION: The future of psychiatric care and psychiatric nursing will be linked to continuing efforts to prevent
mental health problems and to treat coexisting disorders more effectively
33. When the nurse establishes a therapeutic relationship with a client. Which of the following is the primary
focus for the client's care?
a. The medical diagnosis
c. The nursing diagnosis
b. The client's needs and problems
d. The client's social interaction skills
ANSWER: B
The primary focus of a therapeutic relationship is to help the client work on his needs and problems. Although the
medical diagnosis and nursing diagnosis are important in identifying and understanding the client's disorder, they
are not part of the therapeutic relationship. Improving social interaction skills may be one of the nursing
interventions, but it is not the purpose of the relationship.
Reference: Norman Keltner. Psychitric Nursing 5th edition Page
34. While reviewing the charts of assigned clients with physical illness as well as mental illness, you notice that
the psychiatrist has listed the five axes of the current diagnostic and statistical manual published by the American
Psychiatric Association and has filled in information on each axis. Which axis would you find the general medical
conditions listed?
a. Axis I
b. Axis II
c. Axis IV
d. Axis III
ANSWER: D
Each axis represents a different component of a client diagnosis. Axis III is related to general medical conditions.
Axis I includes Clinical Psychiatric Disorders, Axis II relates to Personality Disorders or Mental Retardation, and
Axis IV includes Psychosocial and Environmental Problems.
Reference: Norman Keltner. Psychitric Nursing 5th edition Page 12
35. The parent of a young adult with a diagnosis of schizophrenia asks the nurse why the state mental hospitals
don't take care of the mentally ill like they did in the 1950s and earlier. The nurse explains the failure of
deinstitutionalization in treating clients with mental illnesses by moving them out of the hospital and into the
community. This experiment resulted in the establishment of current admissions criteria. Which of the following
reasons was one of the two major reasons behind deinstitutionalization?
a. The nurses and attendants in the hospital thought "patients" were mistreated.
b. Society pushed for the "least restrictive setting for treatment" of the mentally ill.
c. Significant others wanted their loved ones living with them once more.
d. The mentally ill staged demonstrations demanding they be released.
ANSWER: B
Society pushed for the release of clients with mental disorders into the community as being the least restrictive
setting for treatment. Unfortunately, follow up therapy with these clients was poor and left many of them off their
antipsychotic medications, living in cardboard boxes or prison cells, and living in fear of the manifestations of
their disorders. Family members need to know that it is often necessary to place clients into inpatient settings to
obtain control of their disorders. Sometimes, this is the least restrictive setting for treatment.
Reference: Norman Keltner. Psychitric Nursing 5th edition Page 7
36. Which of the following nurse’s statements best reflects understanding of therapeutic milieu?
a. “At first, the staff makes decisions for the client. As the client demonstrates improvement, the staff provides
the client with more choices.”
b. “Our unit balances group well-being with client autonomy.”
c. “We provide the least restrictive safe environment. Clients participate in their treatment and aftercare planning.”
d. “Our unit has a schedule and a strict routine. Clients are informed of the rules upon admission.”
ANSWER: C
A therapeutic milieu is a structured group setting in which the existence of the group is a key force in the
outcome of treatment. Using the combined elements of positive peer pressure, trust, safety and repetition, the
therapeutic milieu provides an idealized setting for group members to work through their psychological issues.
These statements identify the unique characteristics of milieu therapy: the least restrictive environment and
utilization of the client’s strengths to move toward wellness. Option A: This approach is inconsistent with the
philosophy of the least restrictive environment. Option B: These are characteristics of many institutions. Option
D: This approach is characteristic of many community living situations.
Reference: Norman Keltner. Psychitric Nursing 5th edition Page 285
37. If a nurse is going to assume an active role in mental health promotion in the realm of primary prevention,
which of the following activities would be included?
1. Educate children about the dangers of drug abuse.
2. Participate in depression screening
3. Teach medication management to those clients who have been diagnosed with a mental illness.
4. Recognize which clients have obvious risk factors that could predispose them to developing a mental illness.
a. 1 and 2
b. 3 and 4
c. 1 and 4
d. 2 and 3
ANSWER: C
Primary prevention begins with healthy people and prevents them from being affected by a mental disorder.
Education about the dangers of drug abuse and recognizing clients with modifiable risk factors are both important
in primary prevention. Depression screening is part of secondary prevention as the client has already developed
the disorder. Teaching medication management is a form of tertiary prevention as the nurse is helping clients to
recover and prevent further disability.
Reference: Norman Keltner. Psychitric Nursing 5th edition Page
38. A 57-year-old woman volunteers 3 days a week at a homeless shelter, assists grandmothers raising
grandchildren, and reads to clients at a nursing home. According to Erickson’s Theories of Personality
Development, this woman’s behaviors are age appropriate for which developmental crisis?
a. Generativity and self-absorption
c. Intimacy and isolation
b. Trust and mistrust
d. Industry and inferiority
ANSWER: A
Generativity and stagnation (self-absorption) describes middle adulthood. Trust and mistrust describes the crisis
of the infant. Intimacy and isolation describes the crisis of early adulthood. Industry and inferiority is the crisis of
the school age child.
Reference: Norman Keltner. Psychitric Nursing 5th edition Page 38
39. Freud, founder of psychoanalysis, developed a theoretical framework in which individuals proceed through a
pathway of psychosexual stages of development from birth to adulthood. A child who has difficulty relating to
peers outside of the family home is exhibiting conflict in which of Freud’s Psychosexual States of Development?
a. Anal
b. Genital
c. Oral
d. Latency
ANSWER: D
Oral. Fixation of oral stages can produce dependency in the adult.
Anal. Fixation at the anal stage can produce rigidity and retentiveness.
Genital. Fixation in the genital stage can result in the inability to form satisfying intimate relationships.
Latency. Fixations can result in difficulty with social skills and identifying with others outside the home.
40. In order for a nurse to effectively use Peplau’s theory of interpersonal relations, the nurse must first:
a. Have a baccalaureate level of education.
b. Deal effectively with personal feelings.
c. Demonstrate comprehensive knowledge about therapeutic communication.
d. Care about the client with problems.
ANSWER: C
Peplau’s nursing theory on nurse-client relationships begins with the nurse’s self-awareness and ability to deal
with personal feelings. Option A: Peplau’s nursing theories are used by registered nurses regardless of
educational preparation. Option C: Having a comprehensive knowledge about therapeutic communication is
helpful but it is the active use of self that is essential to work effectively with clients. Option D: Peplau
emphasized the active relationship between the nurse and the client. Self-awareness is the essential element
needed to stay focused on client care.
Reference: Norman Keltner. Psychitric Nursing 5th edition Page
41. A nurse is caring for a client experiencing social isolation. Using Peplau’s interpersonal theories as a
framework for providing nursing interventions, the nurse will focus on:
a. Exploring the client’s specific perception of events.
c. Evaluating the client’s activities of daily living.
b. Changing the client’s assigned room.
d. Improving the client’s interactional skills.
ANSWER: D
Teaching the client relational skills will assist in the development of new ways of relating to others. Option B:
Changing the room is not based on interpersonal skills for isolation. Option C: Changing the client’s activities of
daily living does not directly result in decreased isolation. Option A: This is a helpful step in the nursing process
but the question asks for an intervention for social isolation that is based on interpersonal theories.
Reference: Norman Keltner. Psychitric Nursing 5th edition Page
42. A nurse plans to help a client develop better coping mechanisms. The nurse is aware that according to Peplau
this would take place during which phase of the client relationship?
a. Orientation
b. Resolution
c. Working
d. Termination
ANSWER: C
Orientation. The first stage of the relationship is to become acquainted and establish goals for the relationship.
Working. This is the stage at which the nurse helps the client develop better coping skills.
Termination. This is the final stage of the relationship and takes place after the client accomplishes goals.
Resolution. Resolution occurs after the client successfully achieves the task.
Reference: Norman Keltner. Psychitric Nursing 5th edition Page
43. According to psychoanalytic theory, the superego is concerned with:
a. The desire to seek pleasure while avoiding pain.
b. Mutually satisfying relationships with others.
c. The ability to delay an immediate release of tension or achievement of pleasure.
d. Moral behavior.
ANSWER: D
The superego focuses on moral behavior. Option A: The pleasure principle seeks pleasure and avoids pain and is
a function of the id. Option B: Achieving mutually satisfying relationships with others is under the control of the
ego, not the superego. Option C: The reality principle, a learned ego function, delays the immediate release of
tension or achievement of pleasure.
Reference: Norman Keltner. Psychitric Nursing 5th edition Page
44. The nurse asks the client to describe what the client was feeling prior to an outburst of aggressive behavior
during group therapy. The nurse is utilizing what theoretical framework?
a. Social–interpersonal
c. Medical–psychobiologic
b. Cognitive behavioral
d. Psychoanalytic
ANSWER: B
Cognitive behavioral interventions focus on what the client thinks and feels and identifies the meaning of
behavior. Option A: Social–interpersonal theory focuses on the client’s past and present relationships. Option C:
The medical–psychobiologic theory believes mental illness responds to physical and somatic treatment and the
nurse is responsible for the client’s physical well-being. Option D: Psychoanalysis is typically practiced in
outpatient settings and nurses are not included in the psychoanalytical process.
Reference: Norman Keltner. Psychitric Nursing 5th edition Page 35
45. A psychiatric nurse is conducting a skills group. The focus of the agenda for the group is to practice assertive
behavior skills and enhance their self-esteem. For a client who has exhibited poor self-esteem, the psychiatric
nurse would evaluate cognitive behavior as successful if the client states
a. “I believe that I am stupid”
c. “I believe I can master that situation”
b. “I believe that everyone knows I will fail”
d. “I believe that this is much too difficult for me”
ANSWER: C
This would indicate the client is in the process of gaining mastery and verbalizing skill achievement. Option A:This
statement suggests frustration and a lack of skill acquisition. Option B: This statement suggests frustration and a
lack of skill acquisition. Option D: This statement suggests a lack of skill acquisition.
Reference: Norman Keltner. Psychitric Nursing 5th edition Page 130
46. A client states “I feel so sad. I don’t think I can go on anymore.” Which of the following is the most
therapeutic response by the nurse to this client?
a. “You feel like you can’t go on anymore?”
c. “Why do you feel like that?”
b. “Things will look better tomorrow.”
d. “I will tell your doctor about your feelings.”
ANSWER: A
This statement is a restatement and allows the client to clarify the intent of the statement. Option B: “Things will
look better tomorrow.” This is false assurance. Option C: “Why do you feel like that?” Asking clients “why”
questions implies criticism of the client. Option D: “I will tell your doctor about your feelings.” This is non
therapeutic since the nurse takes over an action that the client is capable of doing.
Reference: Norman Keltner. Psychitric Nursing 5th edition Page 93
47. During an interaction with a female client, several of the nurse’s nonverbal messages are hindering the
conversation. Which of the following nonverbal behaviors by the nurse would effectively facilitate the interaction?
1. Sit back with legs crossed at the ankles as the client leans forward.
2. Glance over at the clock on the wall as the lunch cart is wheeled into the room.
3. Smile as the client begins to discuss her latest alien abduction.
4. Rub the client’s shoulders when her eyes begin to well up.
5. Make frequent brief eye contact with the client.
6. Remain seated as the client inches her chair in the opposite direction.
a. 1, 3, 5, 6
b. 3, 4, 5, 6
c. 5 and 6
d. All except 3
ANSWER: C
Make frequent brief eye contact with the client is correct because it encourages conversation. Remain seated as
the client inches her chair in the opposite direction is correct as the nurse is respecting the client’s boundaries
and need for personal space.
1. Sit back with legs crossed at the ankles as the client leans forward is not correct because it appears selfprotective and does not
mirror the client’s action.
2. Glance over at the clock on the wall as the lunch cart is wheeled into the room is incorrect because it shows
the nurse’s distraction and preoccupation with events on the unit.
3. Smile as the client begins to discuss her latest alien abduction is incorrect because it ridicules and insults the
client’s dignity. Healthy humor is an effective tool but not when laughter is directed at the client’s bizarre
delusion.
4. Rub the client’s shoulders when her eyes begin to well up is incorrect because it may be culturally
inappropriate. The nurse should first ask for permission before touching the client.
Reference: Norman Keltner. Psychitric Nursing 5th edition Page
49. A client reports losing his job, not being able to sleep at night, and feeling upset with his wife. The nurse
responds to the client, "You may want to talk about your employment situation in group today." The nurse is
using which therapeutic technique?
a. Restating
b. Making observations
c. Exploring
d. Focusing
ANSWER: D
The nurse is using focusing by suggesting that the client discuss a specific issue. She is concentrating on a single
point which may prevent a multitude of factors from overwhelming the client. She didn't restate the question
(restating) or ask further questions (exploring), and didn't make an observation.
Reference: Videbeck, S. L. (2004) Psychiatric Mental Health Nursing. 2nd edition. Lippincott Williams and Wilkins.
116
50. The nurse and physician are discussing a therapeutic approach for a client experiencing depression. The
nurse states that clients have control over their own lives. What therapeutic approach does this opinion
represent?
a. Interactionism
b. Conditioning
c. Psychoanalysis
d. Humanism
ANSWER: A
Interactionism. The belief that individuals control their own lives and events is the basis of interactionism.
Humanism. The central concept of humanism is to work for well-being within the limitations of life.
Psychoanalysis. Clarifying the meaning of feelings, events, and behavior is the basis of psychoanalysis.
Conditioning. Conditioning discovers the Rationale for a behavior response and what reinforces the behavior.
Reference: Norman Keltner. Psychitric Nursing 5th edition Page
51. One effective way to start an interaction with a client is to:
a. Tell the client something about yourself and hope that the client does the same
b. Remain silent, waiting for the client to bring up a topic
c. Bring up a controversial topic to elicit the client’s response
d. Introduce a neutral topic, giving the client a broad opening
ANSWER: D
This is the list threatening. Answer b, is not good because the nurse needs to intervene into a pattern of silence.
It is not therapeutic for the focus to be on the nurse, as in answers a and c, and bringing up a controversial topic
(such as religion or politics) usually results in an exchange of opinions and arguments.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 116
52. A client in group therapy is restless. His face is flushed and he makes sarcastic remarks to group members.
The nurse responds by saying, "You look angry." The nurse is using which technique?
a. Giving a broad opening
b. Reassuring
c. Clarifying
d. Making observations
ANSWER: D
The nurse is using observation to give the client feedback about his behavior and attitude. This is verbalizing
what the nurse perceives. This is used when the client sometimes cannot verbalize or make themselves
understood or the client may not be ready to talk. A broad statement doesn't give feedback to the client. The
nurse didn't ask the client to explain his actions (clarifying) and didn't reassure the client.
Reference: Videbeck, S. L. (2004) Psychiatric Mental Health Nursing. 2nd edition. Lippincott Williams and Wilkins.
117
53. Unhealthy personal boundaries are a product of dysfunctional families and a lack of positive role models.
Unhealthy boundaries may also be a result of:
a. structured limit setting
c. abuse and neglect
b. supportive environment
d. direction and attention
ANSWER: C
Abuse and neglect lead to poor self-concept and role confusion, the basis for unhealthy personal boundaries.
Healthy boundaries are established in childhood when parents provide consistent, supportive limits and attention.
Reference: Videbeck, S. L. (2004) Psychiatric Mental Health Nursing. 2nd edition. Lippincott Williams and Wilkins.
54. A nurse places a client in full leather restraints. How often must the nurse check the client's circulation?
a. Every 4 hours
b. Once per shift
c. Every 30 minutes
d. Every 2 hours
ANSWER: C
Other information about restraints:
Assess restraints every 30 minutes (circulation checks, skin assessment etc.)
Release all restraints every 2-4 hours and provide ROM exercises and skin care, offer food, fluids and bathroom
break.
Ensure that a physician’s order has been provided or if during an emergency, obtain one within 24 hours after
applying the restraint (Kozier, 2004) or 12 hours after applying the restraint (Videbeck, 2004)
Reference: Videbeck, S. L. (2004) Psychiatric Mental Health Nursing. 2nd edition. Lippincott Williams and Wilkins.
181
55. Emergency restraints or seclusion may be implemented without a physician's order under which of the
following conditions?
a. When a written order will be obtained from the primary physician within 24 hours
b. It is never done
c. If a voluntary client wants to leave against medical advice
d. When a minor child is out of control
ANSWER: A
The primary physician in charge of a client's care must write an order for the restraint within 8 hours. In an
emergency, a client who is a threat to himself or others may be restrained without an order. Voluntary clients
have the right to leave against medical advice. A minor is treated the same as an adult regarding restraints.
Reference: Videbeck, S. L. (2004) Psychiatric Mental Health Nursing. 2nd edition. Lippincott Williams and Wilkins.
181 and Kozier, B. (2004) Fundamentals of Nursing. 7th ed. Page 689
56. The nurse is assessing a client's intelligence. Which factor should the nurse remember during this part of the
mental status exam?
a. Acute psychiatric illnesses impair intelligence.
b. Intelligence is influenced by social and cultural beliefs.
c. Poor concentration skills suggests limited intelligence.
d. The inability to think abstractly indicates limited intelligence.
ANSWER: B
Social and cultural beliefs (option B) have significant impact on intelligence. Chronic psychiatric illness may
impair intelligence (option A), especially if it remains untreated. Limited concentration does not suggest limited
intelligence (option C). Difficulties with abstractions are suggestive of psychotic thinking (option D), not limited
intelligence.
57. Nurses conducting a health assessment on an older adult need to assess for the predominant theme that
characterizes stress in older adults. The major stressor of older people is:
a. Loss
b. Food
c. Money
d. Family
ANSWER: A
Major losses for older people include the loss of close relatives and friends through death, loss of mobility,
inability to communicate well, moving, loss of physical ability, loss of health, loss of financial stability, loss of
belongings from moving to a smaller home, and many more losses. Loss is the theme for the stressors in older
persons' lives.
Reference: Antai-Otong. Psychiatric Nursing: Biologic and Behavioral Concepts 2nd edition

58. Modeling in the theory of modeling and role modeling by Erickson, Tomlin, and Swain has as its goal which of
the following?
a. Taking on characteristics of the one modeling
b. Understanding the client’s world from the client’s perspective
c. Identifying at least one purpose in life
d. Identifying strengths and limitations, and effecting change
ANSWER: B
Modeling involves nursing assessment. The goal is for the nurse to develop an understanding of the client’s
subjective experience. Modeling requires empathy to understand the client’s view of the current situation, and in
this way it differs substantially from the nursing assessment as traditionally incorporated in the nursing process.
Reference: Cavan Frisch. Psychiatric Mental Health Nursing 4th edition
59. The mother of a teenager asks the nurse at what age a child's personality is completely formed. A nurse
applying psychoanalytic theory to this question would answer that the personality is almost completely formed by
what age?
a. 5
b. 8
c. 18
d. 21
ANSWER: A
According to psychoanalytic theory, the personality is almost completely formed by 5 years of age.
Reference: Deborah Antai-Otong, Psychiatric Nursing:Biologic and Behavioral concepts. 2nd edition
60. The nurse assesses an adult client who admits to being a nail-biter when the nurse observes extreme
shortness and unevenness of the client's nails. The nurse recalls that people who bite their nails are said to be
fixated at which of the following stages in Freud's stages of psychosexual growth and development?
a. Oral
b. Latency
c. Genital
d. Prepuberty
ANSWER: A
The development of orally focused habits such as smoking and nail-biting are associated with fixation at the oral
stage of development in Freud's theories of the stages of psychosexual growth and development.
Reference: Deborah Antai-Otong, Psychiatric Nursing:Biologic and Behavioral concepts. 2nd edition
SITUATION: The field of psychiatric nursing has undergone many changes through the years, and it is important
to seek out some of the historical trends which have brought the career to where it is now.
61. The major driving force behind current mental health treatment models is which of the following forces?
a. Potential to cause harm
c. Availability of improved neuroleptic medications
b. Managed care principles
d. Concern for humane treatment of the mentally ill
ANSWER: B
Because of the dramatic influence of managed care on health care delivery systems, acutely ill clients are most
likely to be diverted from hospitalization or receive shorter lengths of stay.
Reference: Deborah Antai-Otong. Psychiatric Nursing: Biological and Behavioral Concepts 2nd edition
62. Pinel is best known for which of the following major changes in mental health treatment?
a. Removing the chains from the mentally ill and providing humane treatment
b. Discovering the benefit of chlorpromazine (Thorazine) for treating the mentally ill
c. Promoting the use of better trained personnel in hospitals for the mentally ill
d. Moving the treatment of the mentally ill from the large state institutions to the community
ANSWER: A
Philippe Pinel was placed in charge of Bicetre, a large hospital for the mentally ill. He demonstrated that the
mentally ill improved when released from their chains and provided humane treatment. His work brought
sweeping changes in French institutions for the mentally ill.
Reference: Deborah Antai-Otong. Psychiatric Nursing: Biological and Behavioral Concepts 2nd edition
63. When working in any setting, a nurse following the theories of Peplau would focus most on doing which of the
following things when entering a client's room or meeting with a client?
a. Checking for any threats to safety
c. Assessing the client's strengths and limitations
b. Identifying the roles of significant others
d. Building a relationship of mutual understanding
ANSWER: D
Hildegard Peplau wrote Interpersonal Relations in Nursing: A Conceptual Framework of Reference for
Psychodynamic Nursing. She asserted that all nurse-client interactions are opportunities to build a mutual
understanding and that identifying goals has an impact on client outcomes and responses.
Reference: Deborah Antai-Otong. Psychiatric Nursing: Biological and Behavioral Concepts 2nd edition
64. The first psychotropic medication to be used widely in the treatment of mental illness was which one of the
following medications?
a. Elavil (amitriptyline)
b. Haldol (Haloperidol)
c. Eskalith (lithium carbonate)
d. Thorazine (chlorpromazine)
ANSWER: D
Psychotropics emerged in the 1950s with the introduction of Thorazine (chlorpromazine) to reduce psychiatric
symptoms. While Haldol (Haloperidol) is a psychotropic, it was not introduced until the 1970s. Elavil
(amitriptyline) is tricyclic used for depression, and Eskalith (lithium carbonate) is used for bipolar disorder.
Reference: Deborah Antai-Otong. Psychiatric Nursing: Biological and Behavioral Concepts 2nd edition
65. In the 1800s, “inmates” (clients) in asylums for people who were mentally ill often never left once they were
committed, due to a number of factors that included which of the following?
a. Life in the asylum was significantly better than living in society.
b. Asylums were designed as permanent residences for people who were mentally ill.
c. Inmates who were “good” workers were needed to maintain the asylum.
d. Inmates were unable to afford to pay an attorney to have their commitment overturned.
ANSWER: C
Inmates were frequently not released from the asylums because they were good workers. While they were given
time to read and relax, they provided the major workforce for the daily chores to be completed at the asylums.
Reference: Noreen Cavan Frisch. Psychiatric Mental Health Nursing 4th edition
66. The psychiatric-mental health nurse is working with the new nurse who is orienting to the psychiatric unit.
Which comment by the new nurse indicates to the nurse that further clarification of the generalist nursing role is
needed?
a. "I am a little nervous about conducting psychotherapy with clients."
b. "I would feel better if you would look at my documentation that addresses progress toward treatment goals."
c. "I am doing some reading on how to incorporate complementary interventions into treatment plans."
d. "I will spend time each day evaluating the effectiveness of the therapeutic milieu."
ANSWER: A
The intent to conduct psychotherapy with clients is not consistent with the role of the nurse at the generalist level
of practice as outlined in the Psychiatric-Mental Health Nursing Standards of Practice and indicates a need for role
clarification. Evaluation of the therapeutic milieu, documenting progress toward treatment goals, and
incorporating complementary interventions are consistent with the roles of the psychiatric-mental health nurse
practicing at the generalist level.
Reference: Kneisl. COntemporaryPsychiatric Mental Health Nursing 2nd edition
67. The client asks the nurse if certain changes can be made in the unit milieu. Which action by the nurse
indicates understanding of the nursing role in the therapeutic milieu? The nurse:
a. Discusses the desired changes with the client.
b. Instructs the client that no changes can be made.
c. Refers the client’s requests to the psychosocial rehabilitation worker.
d. Refers the client’s requests to the psychiatric social worker.
Answer: A
The psychiatric-mental health nurse has major responsibility for the milieu; therefore, it is appropriate to discuss
requested changes in order to gather information regarding the effectiveness of the milieu. The psychiatric social
worker identifies community resources and may perform counseling. It is non-therapeutic to instruct the client
that no changes can be made before gathering data in relation to the client’s requests. The psychosocial
rehabilitation worker teaches day-to-day skills for living and may provide case management services.
Reference: Kneisl. COntemporaryPsychiatric Mental Health Nursing 2nd edition
68. Upon arrival on the psychiatric unit this morning, which activity should be the focus of the nurse? The nurse
should:
a. Identify community resources for clients to be discharged this morning.
b. Review psychological testing results for all clients.
c. Schedule the individual therapy sessions for all clients.
d. Assess each client for whom the nurse will be providing care.
Answer: D
The nurse is responsible for implementing the nursing process and nursing care for clients. The psychiatric social
worker has major responsibility for the identification of post-discharge community resources. The clinical
psychologist’s primary foci are psychotherapy and psychological testing.
Reference: Kneisl. COntemporaryPsychiatric Mental Health Nursing 2nd edition
69. Which statement indicates the psychiatric-mental health nurse understands the basic principles of symbolic
interactionism in working with clients?
a. "Clients with mental disorders are unlikely to understand the personal meaning of their experiences."
b. "Clients with altered brain chemistry need frequent reassurance that they should not worry about their
condition."
c. "After my first year of working in mental health, I was able to develop standardized interventions for clients
with the same diagnoses."
d. "I try to avoid interventions that ignore the personal meaning of experiences to my clients."
ANSWER: D
Because all behavior has meaning, the nurse must develop interventions that recognize personal meanings and
are person-specific. Grouping clients by diagnosis and using standardized approaches ignores this premise. In
voicing generalized reassurance, the nurse invalidates the principle that people interpret the world in their own
way. Interactionism stresses that all human beings have purpose and control over their lives, and have personal
understandings of their life experience even if they have altered brain structure and chemistry and stressful
environments.
Reference: Kneisl. COntemporaryPsychiatric Mental Health Nursing 2nd edition
70. Nurse Hannah received the change-of-shift report on a 74-year-old woman admitted for depression. She has
aphasia from a recent stroke and communicates minimally by using pencil and paper. Her college-aged grandson
moved in with her to help with meals and household chores and a home health aide provides daily assistance
with ADLs and medications. For the past week, she has refused to bathe, eats poorly, and has stopped writing.
Which of the following statements best demonstrates that the nurse has the ability to plan holistic care for this
client?
a. The client's psychobiologic health, rehabilitation, self-care potential, and discharge arrangements are
interrelated.
b. The client's quality of life and prognosis are primarily related to her aphasia and inability to communicate.
c. Sudden life changes, such as a stroke, usually lead to depression in older clients.
d. Reliance on the grandson and home health aide have decreased her feelings of self-worth and caused this
episode of depression.
ANSWER: A
A holistic assessment of a client accounts for the interrelated effects of the client's social and cultural
environment as well as psychobiological health. Nurses must not assume they understand the meaning that
symptoms have to the client's quality of life, capacity to improve, or need for independence. While life changes at
any age may lead to altered emotional responses, the nurse must seek to identify the meanings of events in
order to plan effectively.
Reference: Kneisl. COntemporaryPsychiatric Mental Health Nursing 2nd edition
71. If you were to work with the family of a person who has had mental illness for many years and you asked the
family how they felt about neurobiological and genetic research findings, the most likely answer would be:
a. Relief that family interactions are no longer thought to be the major cause of mental illness
b. Happy that their family member will soon be able to be cured of mental illness
c. Upset that findings indicate that some illnesses are due to structural changes
d. Frightened that the person with mental illness will be taking newer, less tested drugs
ANSWER: A
In the past, parents and siblings were thought to be responsible for many mental illnesses, and they have felt
demoralized and blamed for their loved one's illness. With current research demonstrating that the cause of
mental illness is more complex and may include neurobiological and genetic factors, the burden of blame and
guilt is reduced.
Reference: Deborah Antai-Otong. Psychiatric Nursing: Biological and Behavioral Concepts 2nd edition
72. Which of the following ideas held by Hippocrates in the 14th century are still valid in psychiatric-mental
health work today?
a. The hypothalamic-pituitary-adrenal axis has a great deal to do with mental disorders.
b. The brain gives rise to emotions and contributes to disturbances in affect or mood.
c. There is a tenuous balance of four humors in the body that contribute to mood.
d. All persons with mental disorders need to be treated kindly in a relaxing setting.
ANSWER: B
Hippocrates surmised that the brain gives rise to pleasure, joy, pain, and grief, and it contributes to disturbances
in affect and mood. Hippocrates early description of the tenuous balance of four humors (blood, phlegm, and
yellow and black bile) and their relationship to mood disorders proved inaccurate.
Reference: Deborah Antai-Otong. Psychiatric Nursing: Biological and Behavioral Concepts 2nd edition
73. Researchers have suggested that the brain adapts to aging by preserving an abundance of nerve cells rich in
which of the following substances that are linked to higher cortical functioning?
a. GABA
b. Dopamine
c. Acetylcholine
d. Norepinephrine
ANSWER: C
Some researchers have found that the brain adapts to aging by preserving an abundance of nerve cells rich in
acetylcholine in neurotransmitter pathways between the hippocampus and the cerebral cortex. These changes are
linked to higher cortical functioning.
Reference: Deborah Antai-Otong. Psychiatric Nursing: Biological and Behavioral Concepts 2nd edition
74. Which of the following activities, if performed by the nurse, is an example of primary prevention?
a. Assessment of family growth and development
c. Promoting independence in the elderly
b. Identification of problematic behavior in children
d. Screening for depression
ANSWER: A
A psychiatric nurse participates in primary, secondary, and tertiary prevention activities. Primary prevention
includes providing sexual education classes for adolescents, and education programs that promote mental health
and prevent future psychiatric episodes and assessment of family growth and development. Secondary
prevention involves treatment to reduce psychiatric problems (for example, handling crisis intervention in
outpatient setting, administering and supervising medication regimens, and participating in the therapeutic
milieu), identification of problematic behavior, and screening for depression. Tertiary prevention involves helping
clients who are recovering from psychiatric illness; activities directed toward providing aftercare and
rehabilitation are part of this role. Conducting a post discharge support group is a tertiary prevention activity.
Reference: Videbeck, S. L. (2004) Psychiatric Mental Health Nursing. 2nd edition. Lippincott Williams and Wilkins.
72
75. A young adult on the psychiatric ward asks a nurse for a date. Although the nurse realizes this is
inappropriate and declines, the nurse will also:
a. Make certain the client suffers some appropriate consequences for this action
b. Report this client's behavior to the administrator and refuse to work with the client
c. Tell the client that this behavior is inappropriate with a professional nurse
d. Recognize age-appropriate behavior and advise the client of the professional nature of the relationship
ANSWER: D
The young adult is seeking a life mate and dealing with the task of intimacy versus isolation. Although it is
inappropriate for the nurse in a professional relationship to develop an intimate relationship, the nurse needs to
recognize the client's age-appropriate behavior.
Reference: Deborah Antai-Otong. Psychiatric Nursing: Biological and Behavioral Concepts 2nd edition
76. Closely following the beliefs of Harry Stack Sullivan, a psychiatric nurse working with clients would look
closely at what Sullivan referred to as the persona, which is best described as the:
a. "I" or "me"
b. Unconscious
c. Best friend
d. Dark side
ANSWER: A
The persona is what one is talking about when referring to "I" or "me." It could also be called self-concept and
begins developing in infancy with the idea of “good me” and “bad me.”
Reference: Deborah Antai-Otong. Psychiatric Nursing: Biological and Behavioral Concepts 2nd edition
77. Nurse Hannah uses Sullivan’s work when working with clients with mental illness. The main focus of Sullivan's
work was on:
a. Interpersonal relationships
c. Identifying a purpose in life
b. Learned helplessness
d. Insight through gestalt
ANSWER: C
Harry Stack Sullivan focused on interpersonal relationships. He looked at the development of the self-system,
which he called personification. Personification includes all related attitudes, feelings, and concepts about self and
another.
Reference: Deborah Antai-Otong. Psychiatric Nursing: Biological and Behavioral Concepts 2nd edition
78. A basic assumption of Freud’s psychoanalytic theory is that all behavior:
a. Is learned
b. Has meaning
c. Is unconscious
ANSWER: B

d. Is sexually oriented
According to Freud, everything a person does has meaning.
Reference: Deborah Antai-Otong. Psychiatric Nursing: Biological and Behavioral Concepts 2nd edition
79. According to Freud's theory, the ego has several functions. The primary function of the ego is to:
a. Serve as the source of instinctual drives
c. Operate as a conscience that controls unacceptable drives
b. Stimulate psychic energy
d. Test reality and direct behavior
ANSWER: D
The ego tests reality and directs behavior by mediating between the pleasure-seeking instinctual drives of the id
and the restrictiveness of the superego.
Option A and B - the id is the source of instinctual drives and psychic energy.
Option C - the superego also is called the conscience.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 49
SITUATION: A mental health assessment gives the psychiatrist an overall picture of how well the patient feel
emotionally and how well he is able to think, reason, and remember (cognitive functioning).
80. Which of the following best describes the information the nurse will use to construct a nursing care plan?
a. A detailed psychiatric history
c. An intake assessment and reason for admission
b. A mental status examination
d. A psychiatric history and mental status examination
Answer: D
The psychiatric examination consists of the psychiatric history and mental status examination. The intake
assessment and reason for admission are part of the psychiatric history, which includes the client's current
condition, previous diagnosis, interventions, treatments, and a family history.
Reference: Kneisl. COntemporaryPsychiatric Mental Health Nursing 2nd edition
81. Nurse Isabel who is admitting a client to the inpatient unit conducts a comprehensive assessment. How will
Nurse Isabel use the data gathered from the assessment?
1. To plan appropriate interventions
4. To determine the length of stay
2. To make sound clinical judgments
5. To support nursing diagnoses
3. To exclude data from secondary sources
a. 1, 2, 3 only
b. 1, 3, 5
c. 1, 2, 5
d. All except 4
ANSWER: C
Option 1: Assessment data are used in planning appropriate interventions related to the client's need(s). Option
2: Information obtained from the comprehensive assessment is used to make clinical decisions related to the
client's need(s). Option 3: Data are obtained from both primary (client) and secondary (other) sources. Option 4
The length of stay may be estimated at the time of admission, but the determining factor is the client's
progression in response to care. Option 5: Data obtained from the comprehensive assessment is used as support
or evidence for the nursing diagnoses.
Reference: Kneisl. COntemporaryPsychiatric Mental Health Nursing 2nd edition
82. When the nurse assesses the client's affect, the nurse will be observing the client's:
a. Financial resources
c. Way of interacting with others
b. What the client values
d. Emotional responsiveness
ANSWER: D
Affect reflects the client's present state of emotional responsiveness and is observable in the client's body
language.
Reference: Deborah Antai-Otong. Psychiatric Nursing: Biological and Behavioral Concepts 2nd edition
83. Nurse Pepay is working with a client who talks in a steady stream of words, moving rapidly from topic to
topic, and mentioning various famous people, places, and important jobs in the past. She would chart this client's
thought processes as being:
a. Flight of ideas
b. Disorganized
c. Tangential
d. Loose associations
ANSWER: A
Flight of ideas is rapid thinking or ideas that have a common theme. The theme is identified as famous or
important in this case.
Reference: Deborah Antai-Otong. Psychiatric Nursing: Biological and Behavioral Concepts 2nd edition
84. The psychiatric nurse instructs the client to draw clocks with designated times. This nurse is testing the client
for:
a. Memory
b. Visuospatial ability
c. Orientation to time
d. Ability to follow directions
ANSWER: B
Visuospatial ability refers to time and space. Having the client draw clocks with designated times or a geometrical
figure are two ways to test this ability.
Reference: Deborah Antai-Otong. Psychiatric Nursing: Biological and Behavioral Concepts 2nd edition
85. You are working with a client who has a diagnosis of borderline personality disorder. In this case and in other
cases of personality disorders, as well as in clients with cognitive impairment or drug intoxication or withdrawal,
you would mostly expect to find which of the following signs or symptoms?
a. Paranoia
b. Delusions
c. Impulsivity
d. Inappropriate affect
ANSWER: C
Clients with personality disorders, drug intoxication or withdrawal, and disorders of cognitive impairment most
often have difficulty controlling impulses. Paranoia, delusions, and inappropriate affect are generally seen in
clients with schizophrenia and bipolar disorder.
Reference: Deborah Antai-Otong. Psychiatric Nursing: Biological and Behavioral Concepts 2nd edition
SITUATION: Regardless of the treatment setting, rehabilitation program, or population, an interdisciplinary team
approach is most useful in dealing with the multifaceted problems of clients with mental illness.
86. To function as an effective member of the team, the nurse must develop and practice several core skill areas.
Which of the following are pertinent to the development and practice of several core skill areas?
I. Interpersonal skills
V. Communication skills
II. Genuineness and nonjudgmental attitude
VI. Assertiveness
III. Teamwork skills
VII Risk assessment skills
IV. Knowledge
a. I, II, III, IV, V
b. All except VII
c. All except IV
d. All of the above
ANSWER: D
Functioning as an effective team member requires the development and practice of several core skill areas:
•
Interpersonal skills such as tolerance, patience, understanding
•
Humanity such as warmth, acceptance, empathy, genuineness, nonjudgmental attitude
•
Knowledge base about mental disorders, symptoms, behavior
•
Communication skills
•
Personal qualities such as consistency, assertiveness, problem-solving abilities
•
Teamwork skills such as collaborating, sharing, integrating
•
Risk assessment/risk management skills
Reference: Videbeck. Psychiatric Mental Health Nursing. 3rd edition. Page 77
87. A nurse in the management care system collaborates with the treatment team to monitor a client’s progress,
from admission to a community assisted living program. Which of the following roles is the nurse assuming?
a. Advanced practice nurse
b. Nurse manager
c. Case manager
d. Staff nurse
ANSWER: C
Case managers follow the client from admission to discharge and serve as a liaison between the client and
community. Case managers works with clients on broad range of issues, from accessing needed medical and
psychiatric services to carrying out daily tasks. Although they provide different levels of care, both the staff nurse
and the advanced practice nurse provide primary care. The nurse manager supervises other nursing personnel
Reference: Videbeck. Psychiatric Mental Health Nursing. 3rd edition. Page 71-76
88. Which of the following is the primary purpose of psychiatric rehabilitation program?
a. Control the psychiatric symptoms
c. Promote the recovery process
b. Manage client’s medication
d. Reduce hospital readmissions
ANSWER: C
Psychiatric rehabilitation, sometimes called Psychosocial rehabilitation, refers to services designed to promote the
recovery process for clients with mental illness. The recovery goes beyond the symptom control and medication
management to include personal growth, reintegration to the community, empowerment, increased
independence, and improve quality of life.
Reference: Videbeck. Psychiatric Mental Health Nursing. 3rd edition. Page 73
SITUATION: Many theories attempt to explain human behaviors, health and mental illnesses. Each theory
suggests how normal development occurs based on the theorist’s beliefs, assumptions and view of the world. The
following questions refer to this.
89. Which theoretical model is being applied if the nurse believes that behavior can be changed through a system
of reward and punishment?
a. Existential model
b. Developmental theory
c. Interpersonal model
d. Behavioral theory
ANSWER: D
According to the behavioral theory, behavior can be changed though a system of reward and punishments, the
developmental theory explain normal human growth and development and focus on change over time. The
interpersonal model holds that human development results from interpersonal relationships and that behavior is
motivated by avoidance of anxiety and attainment of satisfaction. Existential theory: the behavioral deviations
result when a person is out of touch with himself/herself or the environment. The person who is alienated is
lonely and sad and feels helpless.
Reference: Videbeck. Psychiatric Mental Health Nursing. 3rd edition. Page 49-59
90. According to Freudian theory, in which phase of development do alcoholics tend to be fixated?
a. Anal
b. Phallic
c. Oral
d. Latent
ANSWER: C
Freudian theory, says alcoholics are fixated at the oral phase of development. Psychopathology results when a
person has difficulty making the transition from one stage to the next or when a person remains stalled at a
particular stage or regresses to an earlier stage. Hence, answer a, b, and d, are incorrect
Reference: Videbeck. Psychiatric Mental Health Nursing. 3rd edition. Page 50
91. Which of the following best demonstrates how nurses incorporate Selye’s General Adaptation theory in her
nursing interventions?
a. By teaching clients stress reduction techniques
b. By helping clients to develop an awareness of stressors
c. By examining a client’s life events that require adaptation
d. By explaining to clients how the body responds to stress
ANSWER: D
According to Selye’s general adaptation theory, the body responds to stress in three stages: the first stage is the
alarm reaction, the second stage is resistance, and the third stage is exhaustion if the stress continues. The best
way to incorporate this information into a nursing intervention is to explain how the body responds to stress. The
other choices reflect specific actions the nurse would implement with clients in a stress management program.
Reference:Norman Keltner. Psychiatric Nursing. 5th edition. Pages 120-121
92. The following are psychosocial tasks formulated by Erikson. Which of the following is the task of a middle
adult?
a. Intimacy versus isolation
c. Generativity versus stagnation
b. Industry versus inferiority
d. Trust versus mistrust
ANSWER: C
Generativity is the primary task with middle aged adult and is characterized by parental responsibility and
concern for future generations. The primary developmental task of the young adult is to develop intimacy with
another person while making choices about relationships and career. Industry, a task associated with children
ages 6 to 12, involves active socialization as the child moves from the family into society; much of the child's
energy is focused on acquiring competency. Developing trust is the task of the infant; it's accomplished when the
infant receives adequate mothering and satisfaction of oral needs.
Reference: Videbeck. Psychiatric Mental Health Nursing. 3rd edition. Page 53
93. Which of the following theorists believed that a corrective interpersonal relationship with the therapist was
the primary manner of treatment?
a. Erikson
b. Hildegard Peplau
c. Sigmund Freud
d. Harry Sullivan
ANSWER: D
Sullivan extended the theory of personality development to include the significance of interpersonal relationships.
Sullivan envisioned the goal of treatment as the establishment of satisfying interpersonal relationships. The
therapist provides a corrective interpersonal relationship for the client. Sullivan coined the term Participant
observer for the therapist’s role, meaning the therapists both participates in and observes the progress of the
relationships. Option A: developed the 8 psychosocial stages of development, in each stage the person must
complete a life task that is essential to his/her well-being and mental health. Option B: Peplau developed the
concept of therapeutic nurse-patient relationship, which include four phases: orientation, identification,
exploitation and resolution. During these phases, the client accomplishes certain tasks and makes relationship
changes that help the healing process. Option C: Freud developed the Psychoanalytic theory, it supports the
notion that all human behavior is caused and can be explained. Freud believed that repressed sexual impulses
and desires motivate much human behavior.
Reference: Videbeck. Psychiatric Mental Health Nursing. 3rd edition. Page 53
94. The nurse observes that a mother is highly anxious when caring for her infant. Which of the following
theorists would state that the mother’s anxiety is communicated and internalized by the infant?
a. Freud
b. Sullivan
c. Maslow
d. Erikson
ANSWER: B
Sullivan believed that a child develops a sense of self from the appraisal received from significant others.
According to Sullivan, the infant will internalize the mother’s increased anxiety levels. Options A, C and D are
incorrect.
Reference:Norman Keltner. Psychiatric Nursing. 5th edition. Page 42
95. When Nurse Hannah helps patients change their irrational beliefs to effective problem solving, she is utilizing
what theoretical model?
a. Cognitive Model
b. Reality therapy model
c. Stress Model
d. Humanistic model
ANSWER: A
Cognitive-behavioral focuses on thinking and behaving rather than on expressing feelings. In cognitive-behavioral
model believe that individuals think both rationally and irrationally, and that irrational beliefs or automatic
thoughts are responsible for causing problems because self-defeating behaviors are maintained. Option B: In
Reality therapy model, nurses are regularly involved in helping patients identify reality and factors that interfere
with meeting their needs effectively (reality testing). Option C: Stress Model, provide framework for the nurse to
use to assess the effects of stress on patients and their coping processes. Option D: Humanistic Model, based on
the views of human potential for goodness. Instead of focusing on instinctual drives, humanist therapists focus on
one’s ability to learn about oneself, acceptance of self, and exploration of personal capabilities. Within the
therapeutic relationship, the patient begins to view himself/herself as a person of worth.
Reference:Norman Keltner. Psychiatric Nursing. 5th edition. Page 43-50
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 61
96. The nurse uses several theoretical concepts and approaches and incorporates her own resources in the
practice of psychiatric nursing. The nurse is acting based on which of the following?
a. Limited in scope
b. Eclectic
c. Interaction oriented
d. Needs-oriented
ANSWER: B
Eclectic approach is an individualized style that incorporates the client’s own resources as a unique person with
the most suitable theoretical model. Therapists may specialize in one particular conceptual framework or combine
aspects of different ones. Option C: Interaction oriented approach is used by nurses who rely on interaction and
view themselves as a therapeutic tool and evaluate their actions according to the client’s response. Needsoriented approach, nurses
are actively doing and functioning. Option A: unrelated
Reference: Louise Shives. Psychiatric Mental Health Nursing. 8th edition. Page 30
97. Which of the following responses by the nurse is the best example of clarifying?
a. “Tell me about what you were thinking before you went to talk to him.”
b. “When did you first notice these feelings?”
c. “Instead of talking about your mother, I want to know how you feel.”
d. “I’m having difficulty understanding. Could you explain that to me?”
answer: D
Rationale: Option D is seeking clarification after the nurse was unable to understand the client. Option A is
exploring, option B is placing events in time or sequence, and option C is focusing.
98. During the initial interview with a client, the nurse begins to feel uncomfortable and realizes the client’s
behaviors and mannerisms remind the nurse of her abusive mother. The nurse realizes this phenomena is known
as:
a. Transference.
b. Countertransference.
c. Denial.
d. Reaction formation.
answer: B
Rationale: Countertransference is the nurse’s emotional reaction to clients based on feelings for significant people
in the nurse’s past (option B). Transference is the unconscious process of displaying feelings for significant people
in the past onto the nurse in the present relationship (option A). Denial is a defense mechanism used by
individuals in an attempt to screen or ignore unacceptable realities by refusing to acknowledge them (option C).
Reaction formation is a defense mechanism that causes people to act exactly opposite to the way they feel
(option D).
99. A female client has asked the nurse what she should do about leaving her husband. The nurse replies, “I
think you should divorce your husband because it is just too stressful.” This is an ineffective communication
technique for which reason?
a. It demands an explanation from the client.
c. It belittles the client’s feelings.
b. It disagrees with the client’s actions.
d. It tells the client how to solve her problem.
answer: D
Rationale: Advising clients prevents them from taking responsibility and using the problem-solving process.
“Why” questions (option A) demand an explanation for clients to defend themselves. Disagreeing with the client’s
actions denies clients the right to think and feel as they do (option B). Belittling ignores the importance of the
problem to the client (option C).
100. The nurse who is communicating with a client provides feedback about the client’s statement for which of
the following primary purposes?
a. To give advice
b. To explore feelings
c. To offer information
d. To explain behavior
answer: C
Rationale: Feedback provides the opportunity for the nurse to offer clients information about their verbal and
nonverbal responses. Giving advice (option A) is an ineffective communication technique because the nurse
should avoid giving advice by encouraging clients to solve their own problems. Exploring feelings (option B) and
explaining behavior (option D) may be a part of the therapeutic communication and feedback, but the primary
purpose of feedback is to offer clients information about themselves.
MENTAL HEALTH AND PSYCHIATRIC NURSING
PERSONALITY DISORDERS
SITUATION: All individuals have personality traits and characteristics that make them unique and interesting
human beings. Traits are exhibited in the way individuals think about themselves and others and in the way they
behave.
1. Clients with personality disorders have difficulties in their social and occupational functions. Clients with
personality disorders will most likely:
a. Recover with therapeutic intervention
b. Respond to antianxiety medication
c. Manifest enduring patterns of inflexible behaviors
d. Seek treatment willingly from some personally distressing symptoms
Answer: C
Personality disorders are characterized by inflexible traits and characteristics that are lifelong. Options A and D.
This disorder is manifested by life-long patterns of behavior. The client with this disorder will not likely present
himself for treatment unless something has gone wrong in his life so he may not recover from therapeutic
intervention. B. Medications are generally not recommended for personality disorders.
Reference: Norman Keltner. Pscyhiatric Nursing. 5th edition. Page 469
2. During an initial interview with a client who has personality disorder, the nurse evaluates which of the
following to be present in the client’s personality traits?
a. Changes in the personality that have become about because of stressful event
b. Personality traits that are beyond the range found in most people
c. Personality traits that have changed with advanced age
d. Changes in personality that differ to fit the situation
ANSWER: B
Personality characteristics are formed to early teens. The characteristics are set and stable over time. Events and
situations may make characteristics more apparent, but these characteristics do not change. Changes in
personality in advance age are potentially related to medical condition. The prolonged stability of the personality
structure makes treating personality disorders a difficult and long process
Reference: Norman Keltner. Pscyhiatric Nursing. 5th edition. Page 469
3. A teenage girl was diagnosed to have borderline personality disorder. Which manifestations support the
diagnosis?
a. Lack of self esteem, strong dependency needs and impulsive behavior
b. Social withdrawal, inadequacy, sensitivity to rejection and criticism
c. Suspicious, hypervigilance and coldness
d. Preoccupation with perfectionism, orderliness and need for control
ANSWER: A
Lack of self esteem, strong dependency needs and impulsive behavior, these are the characteristics of client with
borderline personality. Option B: This describes the avoidant personality. Option C: These are the characteristics
of a client with paranoid personality. Option D: This describes the obsessive compulsive personality
Reference: Norman Keltner. Pscyhiatric Nursing. 5th edition. Page 475-483
4. The plan of care for clients with borderline personality should include:
a. Limit setting and flexibility in schedule
c. Restricting her from other clients
b. Giving medications to prevent acting out
d. Ensuring she adheres to certain restrictions
ANSWER: D
The client is manipulative. The client must be informed about the policies, expectations, rules and regulation
upon admission. Option A: Limits should be firmly and consistently implemented. Flexibility and bargaining are
not therapeutic in dealing with a manipulative client. Option B: There is no specific medication prescribed for this
condition. Option C: This is not part of the care plan. Interaction with other clients are allowed but the client
should be observed and given limits in her attempt to manipulate and dominate others
Reference: Norman Keltner. Pscyhiatric Nursing. 5th edition. Page 475-478
5. The odd-eccentric cluster of personality disorders includes the following except:
a. Paranoid
b. Antisocial
c. Schizotypal
d. Schizoid
ANSWER: B
Cluster A: Odd-eccentric behavior cluster of personality includes the following, Paranoid, Schizoid, schizotypal.
Cluster B: The dramatic-erratic cluster of personality disorders includes the following: Antisocial, Borderline,
Histrionic, Narcissistic, Histrionic
Cluster C: The anxious-fearful cluster of personality disorder: Dependent, Avoidant, Obsessive –compulsive
Reference: Norman Keltner. Pscyhiatric Nursing. 5th edition. Page 483
6. Staff members on the unit are frustrated and angry with a patient diagnosed with Borderline personality
disorder who is attempting to pit members on the various shifts against each other for the inconsistencies
occurring with the patient’s care. In providing care for this client it is important for the head nurse to:
a. Provide limit setting
b. Provide the patient some time alone in the room
c. Reprimand the patient for her behavior and use restraints
d. Understand and allow the patient’s behavior
ANSWER: A
The patient with BPD is often manipulative. Consistency, limit setting and supportive confrontations are
necessary interventions to provide clear expectations regarding patient behaviors. These patients are adept at
sidestepping rules, avoiding consequences, and pitting staff members against each other, all for the sake of
getting what they want. Enforcing unit rules, providing clear structure, and placing responsibility for appropriate
behaviors on the patient, although vigorously resisted, will benefit the person with BPD. Option B,C, and D are all
incorrect
Reference: Norman Keltner. Pscyhiatric Nursing. 5th edition. Page 478
7. A client with borderline personality disorder is defensive and emotionally labile and often becomes suddenly
and explosively angry. When interacting with this client, the nurse would:
a. Point out how angry the client is becoming, and confront the behavior.
b. Take a calm, quiet and non-confrontational approach and avoid arguing with the client
c. Tell the client to calm down and to avoid becoming explosive or restraints will be used
d. Use gentle touch and a caring approach to calm the client
ANSWER: B
The best way to respond to the client with angry behavior is a calm, nonconfrontational, nonargumentative
approach. This will avoid further escalating the client’s behavior. Confronting the client’s behavior could
exacerbate anger and trigger explosive behavior. Telling the client to calm down minimizes the client’s problems,
and the mention of restraints may be perceived as threatening to the client. Touch may also be perceived as
threatening; it is not recommended for a client who may become explosive.
Reference: Norman Keltner. Pscyhiatric Nursing. 5th edition. Page 477
8. A client with borderline personality disorder has a nursing diagnosis of Risk for self-directed violence, which is
related to the client’s self mutilating behaviour. Which of the following would indicate a positive outcome for this
client?
a. The client tells the nurse about not wanting to burn himself
b. The client requests cigarettes at appropriate times
c. The client expresses feelings of anger toward others
d. The client denies feelings of wanting to harm anyone
ANSWER: A
The client directly telling
the nurse not wanting to self mutilate is evidence of responding to nursing
interventions. Option D does not indicate the self mutilating behavior is decreasing and options B and C do not
address the established nursing goals.
Reference: Ann Isaacs. Mental Health and Psychiatric Nursing. Page 92-93
9. In planning care for a client with borderline personality disorder, the nurse should consider which of the
following?
a. The client’s perfectionism
c. The client’s lack of affection
b. The client’s fear of being abandoned
d. The client’s desire to be the center of affection
ANSWER: B
Client with BPD have an extreme instability with a great fear of being abandoned. Their behaviors are
maladaptive but they attempt to keep people close to them. They have poor sense of self, which leads their
behaviors causing problems for others so that they will feel secure. Perfection and the desire to be the center of
attention are descriptions of Histrionic personality disorder. Lack of ability to show affection is found in schizoid
and schizotypal personality disorders
Reference: Norman Keltner. Pscyhiatric Nursing. 5th edition. Page 473-481
10. A client comes to group provocatively dressed and is dramatic in conversation, often straying from the topic.
The nurse should use which of the following approaches to maintain a therapeutic environment in the group?
a. Allow the client to express oneself and encourage independence
b. Address the client with close-ended questions and permit only responses that are relevant
c. Avoid acknowledging the client and speak only to group members who remain on track
d. Reprimand the client for unacceptable behavior and inappropriate dress
ANSWER: B
Histrionic personality disorder is a personality disorder in which the clients seeks attention and has excessive
emotionality. The client with HPD needs to know from the group leader what the boundaries of the group are.
This learning may need to be shown by example. Simply ignoring the client will only escalate behavior, while
allowing or endorsing the behavior will be maladaptive to the group and individual. For clients with personality
disorders, this is how they have learned to have their needs met in the past. Reprimanding the client may lead to
the client’s lack of investment in therapy.
Reference: Norman Keltner. Pscyhiatric Nursing. 5th edition. Page 482
11. Which of the following should Nurse Daniel include in planning to educate client with schizoid personality
disorder?
a. Provide education in large group to encourage socialization
b. Deliver teaching individually in clear and concise manner
c. Present the information in theoretical form
d. Engage the client in therapeutic relationship before providing education
ANSWER: B
The client with schizoid personality is technically minded, they might be thought of as a hermits because of their
shyness and introversion. They respond with short answers to questions and do not initiate spontaneous
conversations. Option A: incorrect - People with schizoid personality do not want to be involved in interpersonal
or social relationships and keep people at an emotional distance. These individuals rarely have close friends and
appear uncomfortable interacting with others.
Reference: Norman Keltner. Pscyhiatric Nursing. 5th edition. Page 473
12. The nurse evaluates a client with schizoid personality disorder to exhibit which of the following behaviors,
except:
a. Social isolation
c. Responds with short answers
b. Restricted emotion
d. Grandiosity and lack of empathy to others
ANSWER: D
Grandiosity and lack of empathy are behaviors of narcissistic personality disorder. Options A,B, and C are
behaviors associated with schizoid personality disorder.
Reference: Norman Keltner. Pscyhiatric Nursing. 5th edition. Page 473-479
13. Which of the following nursing interventions should the nurse include in the plan of care for a client with
schizoid personality disorder?
a. Empathize with the situation and avoid validating the distortions
b. Promote trust by recognizing the distortions
c. Use reality orientation whenever possible
d. Dispel the distortions by identifying their nature
ANSWER: A
Schizoid personality disorder is characterized by a marked detachment from people and events around them.
Such clients lack close friends, spend most of their time alone, and show little emotion. Empathizing with the
client and not endorsing the distortions that validate the client is the appropriate approach. This will allow the
client to trust the nurse as the caregiver. Statements should be used that validate a client’s response and feelings
to the distortions, such as “I can see this is upsetting to you”. Challenging the client’s reality will push away the
client and may elicit an aggressive rection.
Reference: Norman Keltner. Pscyhiatric Nursing. 5th edition. Page 474
SITUATION: A 45-year-old lawyer has been admitted in psychiatric unit and is seeking treatment. His wife was
unhappy with their marriage, tired of his stubborn, perfectionist ways. In terms of his work, he was the youngest
full partner in his firm's history, famous for handling many cases at the same time, would not turn down a new
case, and was never satisfied with the quality of work performed.
14. Based on initial assessment, Nurse Daniel concluded what type of personality disorder to this patient:
a. Antisocial
b. Avoidant
c. Passive-aggressive
d. Obsessive-compulsive
ANSWER: D
Individuals with OCD are perfectionistic and inflexible. These patients are overly strict and often set standards for
themselves that are too high; thus their work is never good enough. They are preoccupied with rules, trivial
details and procedures. Option A: The main feature of antisocial personality disorder is a pattern of disregard for
the rights of others. Option B: Avoidant personality disorder are timid, socially uncomfortable, ad withdrawn.
They feel inadequate and are hypersensitive to criticism. Although they are fearful and shy, patients with
avoidant personality disorder desire relationships but need to be certain of being liked before making social
contact. Option C: A passive aggressive person has difficulty discussing issues and maintaining quality
relationships, they are often inefficient in accomplishing tasks and frustrate those around them.
Reference: Norman Keltner. Pscyhiatric Nursing. 5th edition. Page 470-482
15. Based on understanding of obsessive compulsive personality disorder, which of the following should be
considered before planning care for clients with OCD?
a. The client is eager to become involved in a therapeutic relationship because there is a sense of attachment
b. The client is eager to tell personal stories and have others admire what has been accomplished in the past
c. The client views the therapeutic relationship as a waste of time because the client doesn’t see a personal
behavior problem
d. The client may switch between wanting the therapeutic relationship and pushing it away, depending on what
threat is seen
ANSWER: C
A client with OCD views a therapeutic relationship as waste of time because personal behavior is not recognized
as a problem. A client with dependent personality disorder is eager to start any kind of relationship. Such client
will go anywhere at any time for the sense of attachment and security. Option B: Narcissistic personality
disorder. Option D: borderline personality disorder
Reference: Norman Keltner. Pscyhiatric Nursing. 5th edition. Page 470-482
SITUATION: Gary grew up in a family that consisted of his father, mother, and an older brother. He indicated
that there was not much closeness in his family. He was always left to fend for himself and got in trouble very
early. Despite being bright, he received poor grades in school because he “wasn’t interested”. At the age of 14
he was sent to a youth correctional center for stealing a car and was at the reform school for 18 months. Almost
immediately after being released, he started burglarizing. A diagnosis of Antisocial personality disorder was
made.
16. Based on Gary’s assessment, which of the following should the nurse consider when planning care for Gary?
a. The client’s lack of ability to engage with the nurse
c. The client’s hindered ability to justify actions
b. The client’s attempt to manipulate the nurse
d. The client’s openness and honesty about past experiences
ANSWER: B
Clients with antisocial personality has disregard for the rights of others, which is usually demonstrated by
repeated violations of law. Before the age 15 years, these behaviors are diagnosed as conduct disorder. Affected
individuals engage in unlawful behavior. They are also promiscuous and feel no guilt about hurting others. They
are smooth talkers and they deny and rationalize their. Lying, cheating and stealing are common. The diagnosis
of antisocial personality disorder is based on a history of disordered life functioning rather than on mental status.
Reference: Norman Keltner. Pscyhiatric Nursing. 5th edition. Page 474
SITUATION: Robert, who was an actor, sought consultation in order to improve his capacity to express emotion
on stage. At a rehearsal of a play, he had difficulty portraying a character afflicted with a painful depression
following the death of his beloved wife. He was surprised that his lack of empathy startled and even horrified his
fellow actors. During his initial session, he quoted poetry and was facile with words, ideas, and psychological
constructs. He had long recognized that he felt a “special sense of entitlement,” but he attributed this to his view
of his real assets and accomplishments. “I don’t wish to be immodest, but I am uniquely talented”. He felt that
it was “inevitable” that he would become “the next Joel Torre, the dominant actor of our age.” A diagnosis of
narcissistic personality disorder was made.
17. Because the client has narcissistic personality disorder, plans for nursing intervention should include:
a. Promoting rapport by showing interest in personal stories
b. Making limited interactions and being technical
c. Decreasing the tendency for enhancing by acknowledging that the client is better than others
d. Using reality focus, which occurs by challenging the client’s misrepresentations
ANSWER: A
Engaging, listening, and connecting with the client will build rapport with a client who has narcissistic personality
disorder. The nurse should never encourage grandiosity but must remain nonjudgmental to what the client says.
Limit setting and consistency in approach are used to decrease manipulation and entitlement behaviors, but
approaching in technical manner will impair therapeutic relationship. Realistic short term goals focused on the
here and now are important to decrease the patient’s use of fantasy and to increase responsibility for self.
Supportive confrontation is used to point out discrepancies between that which the patient says and that which
actually exists to increase responsibility for self, thus challenging misrepresentations is not encouraged
Reference: Norman Keltner. Pscyhiatric Nursing. 5th edition. Page 481
18. The nurse is collecting a nursing history on Robert. Which of the following assessments would the nurse
expect to find with Robert?
a. A style of speech that lacks detail
c. A lack of empathy for others
b. An unconscious dependency for others
d. Attempts to promote self-esteem in others
ANSWER: C
The narcissistic patient overvalues himself or herself; needs to be admired; is arrogant, self centered, and self
absorbed; and seems indifferent to criticism of others. This person feels superior and has a sense of entitlement,
demanding, attention, admiration and special favors. Person with this disorder want to feel better or more
important than others, so would not promote self esteem in another person. Their dependency is outwardly
expressed in the need for admiration. Option A: Histrionic
Reference: Norman Keltner. Pscyhiatric Nursing. 5th edition. Page 479
SITUATION: M was a strong willed child who easily refused to do anything that was asked of him. His self-care
skills were still developing. He was not potty trained and would not sleep by himself at night. He has average
intelligence and his behavior was quite purposeful. His hyperactive aspects surface during oppositional phases.
He has refused to pick up toys that he’d pull off shelves. He did not listen and would do what he wanted and
when he wanted to. M was diagnosed with Oppositional Defiant Disorder (ODD). Although oppositional behavior is
often a normal part of development for two to three year olds, M was frequently openly uncooperative and
hostile. His ongoing pattern of defiant and hostile behavior toward authority seriously interfered with his day-today functioning. M
had frequent temper tantrums and refused to comply with adult requests and rules.
19. The following are measures to include in planning care for child with oppositional defiant disorder, except:
a. Encourage the client to express anger in an appropriate verbal manner
b. Assist the parents in defining and maintaining limits through restraints
c. Provide positive feedback for appropriate behaviors
d. Encourage the child to use exercise and activity to expend excess energy
ANSWER: B
Options A, C and D are appropriate measures. Restraints are inappropriate.
Reference: Norman Keltner. Pscyhiatric Nursing. 5th edition. Page 639
20. The nurse questions the parents of a child with oppositional defiant disorder about the roles of each parent in
setting rules on behavior. The purpose of this type of questioning is to assess which element of the family
system?
a. Anxiety levels
c. Knowledge of growth and development
b. Generational boundaries
d. Quality of communication
ANSWER: B
Assessing generational boundaries is to establish clear rules and expectations as part of the parental role.
Although the parents may have anxiety regarding the role of parental rule setting, the nurse’s question is not
adequate to assess the anxiety levels. The question concerns the roles of the parents and the child in rule setting.
It does not provide date regarding knowledge of growth and development or communication quality
Reference: Ann Isaacs. Mental Health and Psychiatric Nursing. Page 196
21. Which behavioural assessment in a child is most consistent with a diagnosis of conduct disorder?
a. Arguing with adults
c. Physical aggression toward others
b. Gross impairment in communication
d. Refusal to separate from care provider
ANSWER: C
Physical aggression toward others is significant criterion consistent with the diagnosis of conduct disorder.
Arguing with adults may indicate lesser disorder, oppositional defiant disorder. Conduct disorder is aproblem that
involves violation of social rules. Gross impairment in communication and refusal to separate from a care provider
are behaviors that are more consistent with other mental disorders that can affect children
Reference: Norman Keltner. Pscyhiatric Nursing. 5th edition. Page 639
SITUATION: Saul complains that he was always “staring out at a world full of goodies that I can never have.”
He felt lonely and isolated, unlovable, undeserving, and unable to experience pleasure. Saul stated that when he
was about 12 years old, he began to get the feeling that he was not like other people and that he felt he was
“repulsive”. He started withdrawing from people and became more and more of a social isolate.
22. A diagnosis of schizotypal personality disorder has been made. Which signs would this client exhibit during
social situations?
a. Aggressive behaviour
b. Paranoid thoughts
c. Emotional affect
d. Independence needs
ANSWER: B
Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid
thoughts. Aggressive behavior is uncommon, although these clients may experience agitation with anxiety. Their
behavior is emotionally cold with a flattened affect, regardless of the situation. These clients demonstrate a
reduced capacity for close or dependent relationships.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 440
23. The nurse formulates a nursing diagnosis of Impaired social interaction related to disorganized thinking for a
client with schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention takes
highest
priority?
a.
Helping
the
client
to
participate
in
b.
Establishing
a
one-on-one
relationship
c.
Exploring
the
effects
of
the
client's
behavior
d. Developing a schedule for the client's participation in social interactions
ANSWER: B
By establishing a one-on-one relationship, the nurse helps the client learn how
situations. The other options are appropriate but should take place only after
established.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 440

social
with
on

the
social

interactions
client
interactions

to interact with people in new

the nurse-client relationship is

SITUATION: The character of a person is shown through his or her personality -- by the way an individual
thinks, feels, and behaves. When the behavior is inflexible, maladaptive, and antisocial, then that individual is
diagnosed with a personality disorder.
24. A nurse is studying personality disorders. What statement would indicate that the nurse can differentiate
between personality traits and personality disorders?
a. "Personality traits are persistent behavior traits that do not significantly interfere with an individual's life."
b. "Personality traits are lifelong maladaptive patterns."
c. "Personality traits are enduring and deviate from societal norms."
d. "Personality traits are rigid, stereotyped behavioral patterns."
Answer: A
Personality traits are persistent behavior patterns that do not significantly interfere with one's life, even though
the behaviors may be annoying or frustrating to others. In contrast, personality disorders are enduring, rigid,
stereotyped behavioral patterns that are lifelong and maladaptive and deviate from societal norms.
Reference: Kneisl C.R. Contemporary Psychiatri-Mental Health Nursing 2nd edition
25. A nurse is working with a client who has a diagnosis of obsessive-compulsive personality disorder. It is
important for the nurse and client to discuss:
a. The effect of anger on perfectionism.
c. The need for medication.
b. The need to feel superior.
d. The link between anxiety and perfectionism.
Answer: D
The person with obsessive-compulsive personality disorder strives at all times to keep the world predictable and
organized. These individuals suffer from excessive fear and anxiety. Anger is not a prominent characteristic of
obsessive-compulsive personality disorder. Medications are not a first line of treatment for personality disorders.
Feelings of superiority are associated with narcissistic personality disorder.
Reference: Kneisl C.R. Contemporary Psychiatri-Mental Health Nursing 2nd edition
26. The nurse is caring for a client with schizoid personality disorder. Which nursing diagnosis is most appropriate
for this client with a cluster A personality disorder?
a. Ineffective individual coping related to high dependency needs
b. Social isolation related to inadequate social skills, craving of solitude
c. Fear related to feelings of abandonment
d. High risk for violence, self-directed, related to poor impulse control
Answer: B
Individuals with schizoid personality disorder show a preference for solitary interests and claim to enjoy being
alone. These individuals typically work at occupations that require minimal social interaction. High risk for selfdirected violence and
fear would be appropriate diagnoses for borderline personality disorder. Ineffective
individual coping related to high dependency needs would be an appropriate nursing diagnosis for dependent
personality disorder.
Reference: Kneisl C.R. Contemporary Psychiatri-Mental Health Nursing 2nd edition
27. Jason, a client with antisocial personality disorder, burps loudly. A staff member asks Jason, “Do you know
why people find you repulsive?” this statement would most likely elicit which of the following client reaction?
a. Defensiveness
b. Embarrassment
c. Shame
d. Remorsefulness
ANSWER: A
When the staff member ask the client if he wonders why others find him repulsive, the client is likely to feel
defensive because the question is belittling. The natural tendency is to counterattack the threat to self image.
Reference: Videbeck, Sheila L. Psychiatric Mental Health Nursing, 2nd edition, Page 383-384
28. Which of the following approaches would be most appropriate to use when faced with a client who is suffering
from narcissistic personality disorder, wherein there are observed discrepancies between what the client states
and what actually exist?
a. Rationalization
b. Supportive confrontation
c. Limit setting
d. Consistency
ANSWER: B
The nurse would specifically use supportive confrontation with the client to point out discrepancies between what
the client states and what actually exists to increase responsibility for self.
Reference: Videbeck, Sheila L. Psychiatric Mental Health Nursing, 2nd edition, Page 395
29. A male client is diagnosed with schizotypal personality disorder. Which of the following signs would this client
exhibit during social gatherings?
a. Paranoid thoughts
b. Emotional affect
c. Independence need
d. Aggressive behavior
Answer: A
Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid
thoughts. They are sensitive to the behavior of others, especially rejection and anger, and feel that they are
different and do not fit in. Paranoid ideation, ideas of reference, and odd beliefs are some of the most prevalent
and unchangeable criteria for this disorder. Fantasies about imaginary relationships might be substituted for real
relationships. They are uncomfortable around people but are interested in others.
Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 473
SITUATION: The patient has been telling the nurse about her alcoholic, abusive husband. She has been married
to him for 16 years. She expresses sadness and frustration about her marriage but states, “How could I leave
him?” “What do I do”, “who will take care of me?”, “I could never live alone?”. The patient was diagnosed with
dependent personality disorder
30. Which among the following diagnostic criteria is consistent with the diagnosis of dependent personality
disorder?
a. Pervasive pattern of social inhibition with feelings of inadequacy and hypersensitivity to negative evaluation
b. Pervasive pattern of preoccupation with orderliness
c. Pervasive and excessive need for being taken care of.
d. Pervasive and excessive emotionally and attention-seeking behavior
ANSWER: C
Option A: Avoidant personality, Option B: Obsessive compulsive personality, Option D: Histrionic personality
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 468,470
SITUATION: Derek worked in a large office as a computer programmer. When another programmer received a
promotion, Derek felt that the supervisor "had it in for him" and would never recognize his worth. He was sure
that his co-workers were subtly downgrading him. Often he watched as others took coffee breaks together and
imagined they spent this time talking about him. If he saw a group of people laughing, he knew they were
laughing at him. He spent so much time brooding about the mistreatment he received that his work suffered and
his supervisor told him he must improve or receive a poor performance rating. This action reinforced all Derek's
suspicions, and he looked for and found a position in another large company. After a few weeks on his new job,
he began to feel that others in the office didn't like him, excluded him from all conversations, made fun of him
behind his back, and eroded his position. Derek has changed jobs six times in the last seven years. Derek has
paranoid personality disorder.
31. Which remark by the nurse would best establish rapport and encourage the client with personality to confide
in the nurse?
a. "I get upset once in a while, too."
b. "I know just how you feel. I'd feel the same way in your situation."
c. "I worry, too, when I think people are talking about me."
d. "At times, it's normal not to trust anyone."
ANSWER: A
Sharing a benign, nonthreatening, personal fact or feeling helps the nurse establish rapport and encourages the
client to confide in the nurse. The nurse can't know how the client feels. Telling the client otherwise, as in option
B, would justify the suspicions of a paranoid client; furthermore, the client relies on the nurse to interpret reality.
Option C is incorrect because it focuses on the nurse's feelings, not the client's. Option D wouldn't help establish
rapport or encourage the client to confide in the nurse
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 437-438
SITUATION: The character of a person is shown through his or her personality -- by the way an individual
thinks, feels, and behaves. When the behavior is inflexible, maladaptive, and antisocial, then that individual is
diagnosed with a personality disorder.
32. Mika threatens to “perform something” to herself if she is to be discharged. Mika was diagnosed with
borderline personality disorder. Which of the following actions by the nurse would be most important?
a. Temporarily ask a family member to stay with her
b. Discuss the meaning of the client’s statement with her
c. Request an immediate extension for the client
d. Ignore the client’s statement because she is using manipulation to get what she needs.
ANSWER: B
Patients with BPD should be assessed for self-injurious behavior or suicide attempts. It is important to ask the
patient about specific self-abusive behavior such as cutting, scratching or swallowing.
Reference: Videbeck, Sheila L. Psychiatric Mental Health Nursing, 2nd edition, Page 392-393
33. Which of the following approaches would be most appropriate to use when faced with a client who is suffering
from narcissistic personality disorder, wherein there are observed discrepancies between what the client states
and what actually exist?
a. Rationalization
b. Supportive confrontation
c. Limit setting
d. Consistency
ANSWER: B
The nurse would specifically use supportive confrontation with the client to point out discrepancies between what
the client states and what actually exists to increase responsibility for self.
Reference: Videbeck, Sheila L. Psychiatric Mental Health Nursing, 2nd edition, Page 395
34. Nurse Hannah documents a suspicious client who exhibits hypersensitivity to criticisms and expresses a
feeling of being taken advantage of, to have which of the following types of personality disorders?
a. Antisocial disorder
c. Paranoid personality disorder
b. Schizotypal personality disorder
d. Borderline personality disorder
ANSWER: C
A client with paranoid personality disorder will have characteristics of being highly suspicious, being
hypersensitive to criticism and have a feeling of being taken advantage of. This is contrasted to other disorders,
such as borderline personality disorder antisocial personality disorder and schizotypal personality disorder. A
client with BPD will project discomfort with criticism by making others feel or look bad. Thus, it appears that such
a client is hypersensitive to criticisms. It is not uncommon for someone with BPD to feel suspicious or be taken
advantage of. Clients with antisocial personality disorder will internalize criticism and are usually the ones who
are taking advantage of others. Persons with schizotypal personality disorder believe they have magical powers
and are preoccupied and superstitious but not paranoid.
Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 472-475
35. The nurse is caring for a client with schizoid personality disorder. When determining the plan of care, the
nurse should consider the client to exhibit which of the following?
a. Quickly becomes attached to the group leader
b. Displays behavior lacking social tact or grace
c. Becomes overly emotional in the group setting
d. Attempts to build intimate relationships with other group members
ANSWER: B
Individuals with schizoid personality disorder have difficulty showing and sharing their emotions. They lack the
desire to be part of a group or have intimacy in their relationships. This leads to inappropriate behaviors and a
lack of social tact and grace in a group or social setting.
Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 473
36. When planning care for a client with avoidant personality disorder, the nurse understands that the best
intervention is to:
a. Allow the client to stay in the room until feeling comfortable with people
b. Avoid acknowledging goals achieved by the client
c. Enable the client to set and drive the goals independent of the nurse
d. Promote self-esteem by praising the client’s success
ANSWER: D
A client with avoidant personality disorder are timid, socially uncomfortable and withdrawn. They feel inadequate
and are hypersensitive to criticism. Although they are fearful and shy, clients with avoidant personality disorder
desire relationships but need to be certain of being liked before making social contacts. When interacting with
someone, this person sounds uncertain and lacks self-confidence and also is afraid to ask questions or speak in
public. Any success and accomplishments by the client should be praised. Goal setting should be a combined
effort by the nurse and client.
Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 483-484
37. Which of the following drugs have been known to be effective in treating obsessive-compulsive disorder
(OCD)?
a. Divalproex (Depakote) and lithium (Lithobid)
b. Chlordiazepoxide (Librium) and diazepam (Valium)
c. Fluvoxamine (Luvox) and clomipramine (Anafranil)
d. Benztropine (Cogentin) and diphenhydramine (Benadryl)
Answer: C
The antidepressants fluvoxamine and clomipramine have been effective in the treatment of OCD.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 659
38. Within several days of hospitalization, a client is observed to wash the top of a table repeatedly. Which initial
intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?
a. Administer a prescribed PRN antianxiety medication.
b. Assist the client to identify stimuli that precipitates the ritualistic activity.
c. Allow time for the ritualistic behavior, and then redirect the client to other activities.
d. Teach the client relaxation and thought stopping techniques.
Answer: C
Initially, the nurse should allow time for the ritual (C) to prevent anxiety. (A) may help reduce the client's
anxiety, but will not prevent ritualistic behavior resulting from the client's ineffective coping ability. (B) is a longterm goal of
individual therapy, but is not directly related to controlling the behavior at this time. (D) lists
techniques that can be used to assist the client in learning new ways of interrupting obsessive thoughts and
resulting ritualistic behavior as treatment progresses.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 472
39. Nurse Isabelle is caring for a client performing obvious rituals. What should be her priority consideration for
this client?
a. Rituals must be interrupted all the time.
c. Performing the rituals serves to decrease the client’s anxiety
b. Suggest a less troublesome ritual
d. Ask the client what is the reason behind the ritual.
ANSWER: C
The purpose served by rituals is anxiety reduction. A ritual should only be interrupted as part of a carefully
crafted program of exposure response prevention. The rationale the client gives for the ritual is seldom helpful in
decreasing the behavior. The substitution of less disruptive behavior only prolongs the treatment process.
Reference: Norman Keltner. Psychiatric Nursing. 4th edition. Page. 421
40. The nurse would assess for which of the following characteristics in the behavior of any client diagnosed with
a personality disorder?
a. Ability to charm and manipulate people
c. Diminished need for approval
b. Desire for interpersonal relationships
d. Disruption in some aspect of his or her life
ANSWER: D
Rationale: To meet DSM-IV diagnostic criteria for a personality disorder, behavioral patterns must be pervasive
and maladaptive, resulting in functional impairment or subjective distress. The other behavioral patterns (options
A, B, and C) are associated with some but not all personality disorders.
41. A 27-year-old woman has been diagnosed with borderline personality disorder. She displays a labile affect,
impulsivity, frequent angry outbursts, and difficulty tolerating her angry feelings without self-injury. A priority
nursing diagnosis for this client is:
a. Anxiety.
b. Risk for self-mutilation.
c. Risk for violence towards others.
d. Ineffective individual coping.
ANSWER: B
Rationale: The priority of care is always client safety. Intervening to minimize a client’s risk of self-harm
maintains a safe environment. The nursing diagnoses of Anxiety and Ineffective individual coping are of
secondary importance to the maintenance of the client’s safety. Although the client is impulsive and exhibits
angry outbursts, more assessment data are required to determine if she is a risk for violence directed toward
others.
42. The nurse assesses for the presence of which of the following etiologic factors that may explain the
dichotomous thinking observed in an individual diagnosed with borderline personality disorder?
a. Gender stereotyping
b. Family enmeshment
c. Perfectionistic standards
d. Physiological under-arousal
ANSWER: B
Rationale: Growing up in a multigenerational enmeshed family system and failure to separate/individuate the self
is associated with the development of borderline personality disorder. Conflict in the area of
separation/individuation can result in splitting or dichotomous thinking-perceiving the self and others as all good
or all bad. The other etiologic factors (options A, B, C) are not associated with the development of dichotomous
thinking.
43. A client recently released from prison for embezzlement has a history of blaming others for his problems and
becoming defensive and angry when criticized. He has expressed neither remorse for his actions nor any
response to his conviction. He claims his actions were justified since his employer did not treat him fairly. He is
displaying characteristics of which personality disorder?
a. Narcissistic
b. Histrionic
c. Antisocial
d. Borderline
ANSWER: C
Rationale: The described behavior reflects DSM-IV diagnostic criteria for antisocial personality disorder. His
behavior is not characteristic of individuals diagnosed with narcissistic, histrionic, or borderline personality
disorder.
44. A 35-year-old client is being interviewed by the nurse. The client’s history indicates that she has few friends,
fears criticism and rejection from others, and withholds information about her thoughts and feelings because she
anticipates a negative reaction. Based on the data, the nurse suspects that the client may have which of the
following personality disorders?
a. Schizotypal
b. Paranoid
c. Avoidant
d. Schizoid
ANSWER: C
Rationale: The described behavior reflects the DSM-IV diagnostic criteria for avoidant personality disorder. Her
behavior is not characteristic of individuals diagnosed with schizotypal, paranoid, or schizoid personality disorder
45. Which nursing diagnosis may be a priority of care at the time of admission for a client diagnosed with
antisocial personality disorder?
a. Personal identity disturbance
b. Fear
c. Risk for violence directed at others
d. Social isolation
ANSWER: C
Rationale: Individuals diagnosed with antisocial personality disorder display decreased impulse control, can be
irritable and aggressive, and lack remorse for their actions. Recognizing the potential risk for violence and
maintaining client safety is the first priority of nursing care. The other nursing diagnoses do not reflect the
behavioral patterns associated with individuals diagnosed with antisocial personality disorder.
46. The nurse anticipates that which of the following interventions would be appropriately ordered for a client
admitted with an axis I diagnosis of major depression and an axis II diagnosis of schizoid personality disorder?
a. Group psychotherapy
b. Individual psychotherapy
c. Family therapy
d. Participation in a support group
ANSWER: B
Rationale: Since individuals diagnosed with schizoid personality disorder have no desire for interpersonal
relationships and are indifferent to the opinions of others, individual rather than group therapy would be the
treatment of choice.
47. The nurse would look for signs of which of the following as a prominent behavioral characteristic of an
individual diagnosed with narcissistic personality disorder?
a. Splitting
b. Hypersensitivity
c. Suspiciousness
d. Entitlement
ANSWER: D
Rationale: A sense of entitlement is reflected in the DSM-IV diagnostic criteria for narcissistic personality
disorder. Splitting, hypersensitivity, and suspiciousness are not behavioral patterns associated with individuals
diagnosed with narcissistic personality disorder.
48. An intervention strategy routinely included in the nursing care plan for a client diagnosed with antisocial
personality disorder is:
a. Establishing clear and enforceable limits.
c. Varying unit rules based on staff needs.
b. Varying unit rules based on client demands.
d. Letting the client have a voice in when unit rules should apply
ANSWER: A
Rationale: As the behavioral patterns of individuals diagnosed with antisocial personality reflect a tendency to
test and manipulate others, it is important to establish the parameters of acceptable behavior upon admission
through limit setting. The other interventions would result in an unstructured environment with no consistent
limits on behavior. This would increase rather than decrease an individual’s tendency to test and try to
manipulate others in the environment.
49. Which of the following interventions would be appropriate for the nurse to implement when caring for the
client with obsessive-compulsive personality disorder?
a. Assertiveness training
b. Decision-making skills
c. Anxiety management
d. Values clarification
ANSWER: B
Rationale: Because they need perfection and control, individuals diagnosed with obsessive-compulsive personality
disorder usually have trouble making decisions. This difficulty frequently negatively effects their occupational
functioning. Learning that decisions do not always have to be perfect and that they can be changed may be a first
small step toward improvement. Individuals with obsessive-compulsive personality disorder tend to be assertive
in stressing the importance or rules and regulations and in arguing in support of their own value system. Anxiety
may occur when their attempts to control the environment fail, but it has less impact on functioning than does
the difficulty in making decisions.
SITUATION: Those with a personality disorder possess several distinct psychological features including
disturbances in self-image; ability to have successful interpersonal relationships; appropriateness of range of
emotion, ways of perceiving themselves, others, and the world; and difficulty possessing proper impulse control.
50. The community nurse is following up on a client who was hospitalized with depressive disorder, not otherwise
specified, following the death of her spouse. In reviewing the client's chart, the nurse notes that the client has an
Axis II diagnosis of dependent personality disorder. Which behaviors would the nurse anticipate in this client?
a. Difficulty making decisions, lack of self-confidence
c. Odd mannerisms, speech, and behaviors
b. Grandiose thinking, attention-seeking behaviors
d. Unstable moods and impulsive behaviors
ANSWER: A
The client with a dependent personality disorder typically demonstrates anxious and fearful behavior and is
reluctant to make decisions. Lack of self-confidence is reflective of chronic low self-esteem. The behavior in
option B is characteristic of someone with a dramatic, emotional, erratic personality disorder, such as narcissistic
personality. The behavior in option C is characteristic of schizoid or schizotypal personality disorder, in which odd,
eccentric behavior is displayed. Option D characterizes borderline personality disorder.
Reference: Lippincott’s Psychiatric Mental Health Nursing 4th edition Page
51. A client with an Axis II diagnosis of histrionic personality disorder behaves in a dramatic fashion and displays
intense emotions when having to wait in the health clinic for an appointment. How can the nurse best respond to
this situation?
a. Call the health care provider and urge that the client be seen immediately because the behavior is disruptive to
others
b. Directly confront the client about the unreasonable nature of the behavior and point out that other people are
also waiting.
c. Explain to the client the reason for the delay in a calm, nonthreatening manner, and offer to reschedule the
appointment if the client wishes to do so.
d. Ignore the client's behavior and avoid confrontation, which can lead to an escalation of the problem.
ANSWER: C
The nurse is modeling appropriate behavior, using a calm and nonthreatening manner to avoid reinforcing the
client's dramatic behavior. Offering to reschedule the client's appointment allows the client a choice, which
respects the client's feelings in a nonjudgmental way. Calling the health care provider and urging her to see the
client immediately would only serve to reinforce the client's inappropriate behavior. Confronting this client would
increase his anxiety and result in an escalation of dramatic behavior. The nurse should attempt to decrease, not
increase, the client's anxiety. Ignoring the client's behavior would be ignoring a problem that is disruptive not
only to the client, but also to other people in the clinic. The client's behavior would most likely become
increasingly dramatic.
Reference: Lippincott’s Psychiatric Mental Health Nursing 4th edition Page
52. A client is hospitalized following a suicide attempt. His history reveals a previous diagnosis of schizoid
personality disorder. Which of the following behaviors would be atypical of a client with this disorder?
a. Actions designed to please the nurse
c. Odd ideas and mannerisms
b. Limited expressions of feelings and emotions
d. Reluctance to join group activities
ANSWER: A
A client with a schizoid personality disorder is typically detached, aloof, and socially isolated. He has no interest in
seeking the approval others and would not behave in ways to please the nurse. The behaviors included in the
remaining options are characteristic of someone with schizoid personality disorder.
Reference: Lippincott’s Psychiatric Mental Health Nursing 4th edition Page
53. A client with an anxious, fearful personality has difficulty accomplishing work assignments because of her fear
of failure. The client has been referred to the employee assistance program because of repeated absences from
work and evidence of an alcohol problem. Which nursing diagnosis would be most appropriate?
a. Ineffective coping
b. Decisional conflict
c. Disturbed thought processes
d. Risk for self-directed violence
ANSWER: A
This client is experiencing difficulty in occupational functioning as well as problems with alcohol; therefore, she
meets criteria for the diagnosis of ineffective coping. Options B and C are incorrect because there is no evidence
in this situation that the client has a conflict regarding a decision or is experiencing altered thinking. Option D is
also incorrect because the client has not expressed thoughts of self-harm or commiitted any acts designed to
harm herself.
Reference: Lippincott’s Psychiatric Mental Health Nursing 4th edition Page
54. Which statement about an individual with a personality disorder is true?
a. Psychotic behavior is common during acute episodes.
b. Prognosis for recovery is good with therapeutic intervention.
c. The individual typically remains in the mainstream of society, although he has problems in social and
occupational roles.
d. The individual usually seeks treatment willingly for symptoms that are personally distressful.
ANSWER:
An individual with a personality disorder usually is not hospitalized unless a coexisting Axis I psychiatric disorder
is present. Generally, these individuals make marginal adjustments and remain in society, although they typically
experience relationship and occupational problems related to their inflexible behaviors. Personality disorders are
chronic, lifelong patterns of behavior; acute episodes do not occur. Psychotic behavior is usually not common,
although it can occur in either schizotypal personality disorder or borderline personality disorder. Because these
disorders are enduring and evasive and the individual is inflexible, prognosis for recovery is unfavorable.
Generally, the individual does not seek treatment because he does not perceive problems with his own behavior
Distress can occur based on other people's reaction to the individual's behavior.
Reference: Lippincott’s Psychiatric Mental Health Nursing 4th edition Page
55. A client describes himself as "very religious, with strong opinions about what is right and what is wrong:' The
client is quite judgmental about beliefs and lifestyles that are "unacceptable." Which statement supports the
nurse's analysis that this client's behavior is typical of someone with a personality disorder?
a. Inflexible behaviors, along with use of rigid defense mechanisms, are characteristic.
b. Judgmental behavior including self-insight is common.
c. Religious fanatics often have personality disorders. .
d. Strong belief systems are common and can help identify evidence of instability.
ANSWER: A
Individuals with personality disorder have inflexible behavior patterns and rigid defense mechanisms. They are
unlikely to change over time. Such individuals generally lack self-insight and are more likely to have external
locus of control thinking (blaming others for problems). Religious fanatics may be motivated by other
psychodynamics (possibly psychotic states). However, strong belief systems do not necessarily mean mental
instability. A mentally healthy person may have belief systems that are strong and that govern conduct.
Reference: Lippincott’s Psychiatric Mental Health Nursing 4th edition Page
56. A client has a history of conflict-filled relationships. Despite an expressed desire for friends, she acts in ways
that tend to alienate people. Which nursing intervention would be important for this client?
a. Establish a therapeutic relationship in which the nurse uses role modeling and role-playing for appropriate
behaviors.
b. Help the client to select friends who are ki!1d and extra caring.
c. Point out that the client acts in ways that alienate others.
d. Recognize that this client is unlikely to change and therefore intervention is inappropriate.
ANSWER: A
A therapeutic relationship shows acceptance, and using role modeling and role-playing can help the client to learn
appropriate behaviors. Option B is an inappropriate and unrealistic solution to the client's problem behaviors.
Option C is also inappropriate because the client is not likely to accept direct criticism of her behavior; such
individuals do not perceive a problem with their own behavior Option D ignores the client's potential for growth
and improvement.
Reference: Lippincott’s Psychiatric Mental Health Nursing 4th edition Page
57. A hospitalized client with antisocial personality disorder stole money from an elderly client on the unit. Which
of the following is the most appropriate for the nurse to say to this client?
a.''Why did you take the money?"
c."The consequences of stealing are loss of privileges."
b."Let's talk about how you felt when you took the money.”
d."This client is defenseless against you."
ANSWER: C
The most appropriate response is to reinforce the consequences of behavior that disregard the rights of others.
Option A is incorrect because this client is likely to rationalize and excuse the behavior. Option B is also incorrect
because the nurse should not encourage the client to provide excuses or explanations of behaviors that are
clearly against the rules. A client with antisocial personality disorder is unlikely to have compassion for others and
typically lacks respect for the rights of others.
Reference: Lippincott’s Psychiatric Mental Health Nursing 4th edition Page
58. A nurse is working with clients who have personality disorders. Which of the following techniques, would the
nurse use to deal with her own feelings that interfere with therapeutic performance?
a. Active listening techniques
c. Forming social relations
b. Challenging the client's assertions
d. Seeking peer or supervisor direction
ANSWER: D
The nurse is likely to have strong reactions to clients with personality disorders, especially those who display
intense emotions and manipulative behaviors. Seeking the direction of peers and supervisors can help clarify
issues and determine the best nursing responses to difficult behaviors. Active listening and challenging the
client's assertions are beneficial techniques to use with clients; however, this question is asking about techniques
to enhance the nurse’s performance. Forming social relationships would not help in dealing with feelings that
interfere with therapeutic performance.
Reference: Lippincott’s Psychiatric Mental Health Nursing 4th edition Page
59. A client with borderline personality disorder is defensive and emotionally labile and often becomes suddenly
and explosively angry. When interacting with this client, the nurse would:
a. Point out how angry the client is becoming, and confront the behavior.
b. Take a calm, quiet, and non-confrontational approach, and avoid arguing with the client.
c. Tell the client to calm down and to avoid becoming explosive or restraints will be used.
d. Use gentle touch and a caring approach to calm the client.
ANSWER: B
The best way to respond to the client with angry behavior is a calm, non-confrontational, non-argumentative
approach. This will avoid further escalating the client's behavior. Confronting the client's behavior could
exacerbate anger and trigger explosive behavior. Telling the client to calm down minimizes the client's problems,
and the mention of restraints may be perceived as threatening to the client. Touch may also be perceived as
threatening; it is not recommended for a client who may become explosive.
Reference: Lippincott’s Psychiatric Mental Health Nursing 4th edition Page
60. A client with borderline personality disorder has a nursing diagnosis of Risk for self-directed violence, which is
related to the client's self-mutilation behavior (burning arms with cigarettes). Which client behavior would
indicate a positive outcome of intervention?
a. The client denies feelings of wanting to harm anyone
c. The client requests Cigarettes at appropriate times
b. The client expresses feelings of anger toward others
d. The client tells the nurse about wanting to burn himself
ANSWER: D
The fact that the client directly tells the nurse about wanting to self-mutilate, rather than acting on these
feelings, is evidence of his responding to nursing intervention. Option A does not indicate that self-mutilating
behavior is decreasing, and options B and C do not address the established nursing diagnosis.
Reference: Lippincott’s Psychiatric Mental Health Nursing 4th edition Page
61. The nurse is working with the family of a client with a personality disorder. Which of the following should the
nurse encourage the family members to work on?
a. Avoiding direct expression of problems within the family
c. Improving self-functioning
b. Changing the client's problem behaviors
d. Supporting the client's defenses
ANSWER: C
Family members typically benefit from working on ways to improve self-functioning. This facilitates ownership of
problems among individuals involved in ongoing relationship difficulties. The direct expression of problems is
helpful and therefore should not be avoided. It would be impossible to change the client's behavior; encouraging
family members to do so would frustrate them. The client's defenses are likely to be quite strong, and this client
is likely to blame others for problems; consequently, supporting his blaming others is not helpful.
Reference: Lippincott’s Psychiatric Mental Health Nursing 4th edition Page
62. The nurse assesses the client with borderline personality disorder. Which of the following behaviors are
common to this diagnosis?
1. Intense fear of being alone
4. Indifferent attitude toward approval or criticism
2. Evidence of self-mutilating attempts
5. Unstable moods with impulsive behaviors
3. Evidence of suspiciousness and mistrust of others
6. Presence of odd mannerisms, speech, and behaviors
a. 1, 2, 5
b. 3, 4, 5
c. 1, 2, 3, 4
d. All except 5
ANSWER: A
These are all common characteristics of an individual with borderline personality disorder. Suspiciousness and
mistrust of others (option 3) is characteristic of paranoid personality disorder. Options 4 and 6 are characteristic
of someone with schizoid personality disorder, who is generally aloof in relationships and has unusual speech and
mannerisms.
Reference: Lippincott’s Psychiatric Mental Health Nursing 4th edition Page
63. When a client with a personality disorder begins demonstrating manipulative behavior, which of the following
nursing actions are most appropriate?
1. Ask the client to think about the consequences of behavior
2. Allow the client time to perform specific rituals
3. Develop a consistent team approach to handle the client's behaviors
4. Help the client to express anxiety verbally rather than with specific symptoms
5. Provide immediate feedback concerning the client's specific behaviors
6. Set limits in a clear, direct manner
a. 1, 3, 4, 6
b. 1, 2, 3, 6
c. 1, 3, 5, 6
d. All except 4
ANSWER: C
These interventions allow the nurse to immediately confront the client's manipulative behavior and provide
consistent structure (through limit-setting and a team approach). Option 2 is appropriate for the client with
obsessive-compulsive behavior; option 4, for someone with a somatatization problem .
Reference: Lippincott’s Psychiatric Mental Health Nursing 4th edition Page
64. Increased levels of testosterone and estrogens and decreased levels of 5-HIAA are associated primarily with
which of the following?
a. Cluster C personality disorders
c. Cluster A personality disorders
b. Cluster A–C personality disorders
d. Cluster B personality disorders
ANSWER: D
Cluster A personality disorders. There are some neuroanatomical commonalities among clients with schizotypal
personality disorder. However, since the commonalities are not associated with schizoid personality disorder or
paranoid personality disorder, these commonalities do not exist across Cluster A.
Cluster B personality disorders. Increased levels of testosterone, 17-estradiol, and estrone have been observed in
people with impulse control problems. The serotonin metabolite 5-HIAA has been shown to be low in people who
attempt suicide and in those with aggression and impulse control problems. Impulse control is associated with
the personality disorders grouped together in Cluster B.
Cluster C personality disorders. There are no known neuroanatomical commonalities across the Cluster C
personality disorders.
Cluster A–C personality disorders. Personality disorders do not fall into dual clusters such as A–C.
Reference: Carol Ren Kneisl. Contemporary Psychiatric-Mental Health Nursing 2nd edition
65. Your client with a personality disorder has a nursing care plan which includes the nursing diagnosis “Impaired
Social Interaction.” Applying the principles for caring with this client, which of the following interventions is
essential to the care plan?
a. Demonstrate unconditional positive regard when confronting inappropriate behavior
b. Assist the client in identifying personal strengths
c. Demonstrate honesty and sincerity in all interactions with the client
d. Role-model assertive communication
ANSWER: C
Establishing a therapeutic relationship with personality-disordered individuals is challenging because it goes
against the basic nature of most personality-disordered clients to trust others and express their true feelings.
Without the foundation for trust, including clear and open communication, other interventions are likely to be
ineffective.
Option B: The nurse can be a credible resource in this regard when the basis for trust has been established.
Option A: This intervention is directed toward increasing self-esteem, and confrontation will be less threatening
within the context of a trusting relationship.
Option D: The client must trust the nurse before the client sees the nurse as a credible role model.
Reference: Carol Ren Kneisl. Contemporary Psychiatric-Mental Health Nursing 2nd edition
66. Your client with a personality disorder informs you, “A novice like you couldn’t possibly help me. What I need
right now is to leave this hospital.” What is your best initial response?
a. “I will notify your physician.”
c. “Where will you go?”
b. “What are you experiencing right now?”
d. “What makes you think I cannot help you?”
ANSWER: B
Encouraging the client to identify thoughts and feelings is the approach most likely to increase the client’s selfawareness. Option A:
This response cuts off further communication, responds only to content and not to what is
happening in the here and now (process), and may be perceived as rejection. Option C: This response focuses on
the content of the client’s statement rather than the process and may serve to escalate the client’s anxiety.
Option D: A defensive response to the client’s suggestion that you cannot help deflects the focus away from the
client.
Reference: Carol Ren Kneisl. Contemporary Psychiatric-Mental Health Nursing 2nd edition
67. Your peer informs you, “This client always disrupts our unit and leaves against medical advice. She is a
typical borderline.” What is your best initial response?
a. “You cannot get away from people with personality disorders. They follow you wherever you go in health care.”
b. “I wish we could identify what she needs and provide it before she acts out on the unit.”
c. “Try not to get angry. It is a waste of your energy, and she will never change.”
d. “Be sure to take care of yourself, because working with these clients is not gratifying.”
ANSWER: B
This statement approaches the client as a person with unique needs and suggests an approach to positively affect
her treatment. Option A:This statement reinforces your peer’s sense of hopelessness. Option C: While this
statement may identify your peer’s feeling, it also reinforces your peer’s sense of powerlessness and does not
address the stereotyping of the client. Option D: This statement affirms the need for self-care, but depersonalizes
the client.
Reference: Carol Ren Kneisl. Contemporary Psychiatric-Mental Health Nursing 2nd edition
68. After being discharged from the hospital less than 24 hours ago, your client with a personality disorder
attempts suicide and is readmitted. You overhear a staff member saying, “Why doesn’t she just kill herself and
put herself out of our misery?” Which of the following is your best response?
a. “She would rather not see you, either.”
b. “It is frustrating to care for people with persistent behaviors.”
c. “That’s a hostile thing to say.”
d. “She probably knows you feel that way about her.”
ANSWER: B
This response demonstrates empathy for your coworker. In addition, it encourages her to continue sharing her
thoughts and feelings without seeming judgmental of her. As the dialogue continues, you may be able to identify
effective treatment interventions for the client. Approaching the client as a united team is most likely to ensure
consistency and minimize the potential for splitting of staff. Option A: This statement is probably engendered by
feeling protective of the client. However, it is important to assist the staff member to identify and ventilate
thoughts and feelings so that the staff member does not act out the feelings with the client. The dynamic of
splitting staff is evident. Option C: Although this statement is true, it is confrontational and sets the stage for
splitting. Option D: This statement highlights the potential lack of safety and comfort for the client that the staff
member’s attitude may convey and potentially causes a split between you and the staff member.
Reference: Carol Ren Kneisl. Contemporary Psychiatric-Mental Health Nursing 2nd edition
69. When assessing a client with a diagnosis of Obsessive-Compulsive Personality Disorder, the nurse would most
expect to find which of the following behaviors consistent with this diagnosis?
a. Checking the door locks over and over again for hours.
b. Giving away belongings and not holding onto things.
c. Wanting everything to be perfect and following the rules.
d. Having repeated intrusive thoughts to shout profanities.
ANSWER: C
The client with Obsessive-Compulsive Personality Disorder is preoccupied with orderliness, perfectionism and
mental and personal control. A client with this pays close attention to rules, trivial details, lists and schedules. A
client with this disorder has a tendency to hold onto things even when they are worn out or useless. This
personality disorder should not be confused with the anxiety disorder of Obsessive-Compulsive Disorder.
Repetitive behaviors and compulsions are common to this disorder.
Reference: Carol Ren Kneisl. Contemporary Psychiatric-Mental Health Nursing 2nd edition
70. When making a home visit to a client with Dependent Personality Disorder, the nurse finds the client agreeing
with everything his mother says. He does this even when it is clearly not in his best interest or when the mother
is saying uncomplimentary things to him. The client acts as if he thinks he is incompetent to do things for
himself. Which of the following is the most likely reason for the client's behavior?
a. Mother is controlling
b. Fear of success
c. Fear of abandonment
d. Client is not capable
ANSWER: C
Clients with Dependent Personality Disorder have submissive, clinging behavior, because they fear separation
and abandonment. They have little self-confidence even though they are capable individuals. The mother may
encourage the dependence by being controlling, or she may be responding out of years of experience with the
client where she has had to make decisions for him. Her resentful might be showing.
Reference: Carol Ren Kneisl. Contemporary Psychiatric-Mental Health Nursing 2nd edition
71. Which of the following behaviors by a client who has a diagnosis of Narcissistic Personality Disorder, would
the nurse find to be consistent with the diagnosis?
a. Isolating and refusing to talk with peers.
c. Compulsively looking in the mirror for hours.
b. Refusing to do anything for himself or herself.
d. Expecting special treatment immediately.
ANSWER: D
Clients with Narcissistic Personality Disorder are full of their own sense of self-importance. Therefore, they see
themselves as superior to others and expect to be treated as special. They think their wishes should be granted
immediately. They may admire themselves in the mirror, but they are not compulsive about looking at
themselves for hours. They will do for themselves activities they feel are in keeping with their importance. They
do not isolate themselves from peers but socialize expecting admiration from their peers.
Reference: Carol Ren Kneisl. Contemporary Psychiatric-Mental Health Nursing 2nd edition
72. Which of the following statements is most likely to be recognized by the nurse as that of a client with
Histrionic Personality Disorder?
a. "My father has been married twice."
c. "My sister is the most unusual person in the world."
b. "I don't want to take my medicine."
d. "I like to do volunteer work."
ANSWER: C
A client with Histrionic Personality Disorder is most likely to use speech that is lacking in detail and designed to
give a general impression without evidence. Therefore, saying that her/his sister is the most unusual person in
the world would be typical for a client with this personality disorder. The other choices lack the dramatic flair.
Reference: Carol Ren Kneisl. Contemporary Psychiatric-Mental Health Nursing 2nd edition
73. A 22-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely evidence
of ineffective individual coping?
a. Inability to make choices and decisions without advice
b. Showing interest only in solitary activities
c. Avoiding developing relationships
d. Recurrent self-destructive behavior with history of depression
ANSWER: A
Individuals with dependent personality disorder typically show indecisiveness, submissiveness, and clinging
behaviors so that others will make decisions for them.
Option B - These clients feel helpless and uncomfortable when alone and don't show interest in solitary activities.
Option C - They also pursue relationships in order to have someone to take care of them.
Option D - Although clients with dependent personality disorder may become depressed and suicidal if their
needs aren't met, this isn't a typical response.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 366-367
74. A client chronically complains of being unappreciated and misunderstood by others. She's argumentative and
sullen. She always blames others for her failure to complete work assignments. She expresses feelings of envy
toward people she perceives as more fortunate. She voices exaggerated complaints of personal misfortune. The
client most likely suffers from which of the following personality disorders?
a. Dependent personality
c. Avoidant personality disorder
b. Passive-aggressive personality
d. Obsessive-compulsive disorder
ANSWER: B
The client with passive-aggressive personality disorder displays a pervasive pattern of negative attitudes, chronic
complaints, and passive resistance to demands for adequate social and occupational performance.
Option A - The client with a dependent personality is unable to make everyday decisions and allows others to
make important decisions. In addition, the client with a dependent personality often volunteers to do things that
are unpleasant so that others will like him.
Option C - The avoidant personality displays a pervasive pattern of social discomfort, fear of negative evaluation,
and timidity.
Option D - The obsessive-compulsive personality displays a pervasive pattern of perfectionism and inflexibility.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 369-370
SITUATION: A client is admitted with a diagnosis of schizotypal personality disorder.
75. Which signs would this client exhibit during social situations?
a. Aggressive behavior
b. Paranoid thoughts
c. Emotional affect
d. Independence needs
ANSWER: B
Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid
thoughts.
Option A - Aggressive behavior is uncommon, although these clients may experience agitation with anxiety.
Option C - Their behavior is emotionally cold with a flattened affect, regardless of the situation.
Option D - These clients demonstrate a reduced capacity for close or dependent relationships.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 353-354
76. The nurse formulates a nursing diagnosis of impaired verbal communication for a client with schizotypal
personality disorder. Based on this nursing diagnosis, which nursing intervention is most appropriate?
a. Helping the client to participate in social interactions
b. Establishing a one-on-one relationship with the client
c. Establishing alternative forms of communication
d. Allowing the client to decide when he wants to participate in verbal communication with the nurse
ANSWER: B
By establishing a one-on-one relationship, the nurse helps the client learn how to interact with people in new
situations. The other options are appropriate but should take place only after the nurse-client relationship is
established.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 353-354
SITUATION: A client has a diagnosis of borderline personality disorder. She has attached herself to one nurse
and refuses to speak with other staff members. She tells the nurse that the other nurses are mean, withhold her
medication, and mistreat her. The staff is discussing this problem at their weekly conference.
77. Which intervention would be most appropriate for the nursing staff to implement?
a. Provide an unstructured environment for the client
c. Ignore the client's behaviors
b. Rotate the nurses who are assigned to the client
d. Bend unit rules to meet the client's needs.
ANSWER: B
Rotating staff members who work with a client with a borderline personality disorder keeps the client from
becoming dependent on any one nurse and reduces the use of splitting behaviors and her fear of abandonment.
Option A - Firm rules and consistency among staff members will help control the client's behavior.
Option C - Ignoring splitting behaviors can cause the client to increase the behavior by trying to get a response
from the staff.
Option D - Unit rules must be consistently enforced and followed by each nurse to help the client control
behavior.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 359-363
78. The nurse expects the assessment to reveal:
a. unpredictable behavior and impulsivity
c. somatic symptoms.
b. inability to function as a responsible parent.
d. coldness, detachment, and lack of tender feelings.
ANSWER: A
A client with borderline personality disorder displays a pervasive pattern of unpredictable behavior, mood, and
self-image. Interpersonal relationships may be intense and unstable and behavior may be inappropriate and
impulsive. Although the client's impaired ability to form relationships may affect parenting skills, inability to
function as a responsible parent is more typical of antisocial personality disorder. Somatic symptoms characterize
avoidant personality disorder. Coldness, detachment, and lack of tender feelings typify schizoid and schizotypal
personality disorders.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 359-363
79. Initial nursing assessment reveals that the client's wrists are scratched from a recent suicide attempt. Based
on this finding, the nurse should formulate a nursing diagnosis of:
a. Ineffective individual coping related to feelings of guilt.
b. Situational low self-esteem related to feelings of loss of control.
c. Risk for violence: Self-directed related to impulsive mutilating acts.
d. Risk for violence: Directed toward others related to verbal threats.
ANSWER: C
The predominant behavioral characteristic of the client with borderline personality disorder is impulsiveness,
especially of a physically self-destructive sort. The observation that the client has scratched wrists doesn't
substantiate the other options.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 359-363
80. Transient psychotic symptoms that occur with borderline personality disorders are most likely treated with
which of the following?
a. Anticonvulsant mood stabilizers
b. Antipsychotics
c. Benzodiazepines
d. Lithium
ANSWER: B
Antipsychotics are drug of choice for borderline personality disorders.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 350
SITUATION: The client has a history of fighting, cruelty to animals, and stealing and has been diagnosed with
antisocial personality disorder.
81. Which of the following traits would the nurse be most likely to uncover during assessment?
a. History of gainful employment
b. Frequent expression of guilt regarding antisocial behavior
c. Demonstrated ability to maintain close, stable relationships
d. A low tolerance for frustration lack of impulse control
ANSWER: D
Clients with an antisocial personality disorder exhibit a low tolerance for frustration, emotional immaturity, and a
lack of impulse control.
Option A - They commonly have a history of unemployment, miss work repeatedly, and quit work without plans
for other employment.
Option B - They don't feel guilt about their behavior and commonly perceive themselves as victims. They also
display a lack of responsibility for the outcome of their actions.
Option C - Because of a lack of trust in others, clients with antisocial personality disorder commonly have
difficulty developing stable, close relationships.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 354-356
82. Which of the following statements is most appropriate for the nurse to make when explaining unit rules and
expectations to the client?
a. "I and other members of the health care team would like you to attend group therapy each day
b. "You'll find your condition will improve much faster if you attend group therapy each day
c. "You'll be expected to attend group therapy each day
d. "Please try to attend group therapy each day."
ANSWER: C
Rules and explanations must be brief, clear, and leave little room for misinterpretation. A client with antisocial
personality disorder tends to disregard rules and authority and be socially irresponsible. The words "You'll be
expected to attend" are concise and concrete and convey precisely what behavior is expected. The other options
leave open the interpretation that attendance is suggested but not mandatory.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 354-356
83. A 22-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely evidence
of ineffective individual coping?
a. Inability to make choices and decisions without advice
b. Showing interest only in solitary activities
c. Avoiding developing relationships
d. Recurrent self-destructive behavior with history of depression
ANSWER: A
Individuals with dependent personality disorder typically show indecisiveness, submissiveness, and clinging
behaviors so that others will make decisions for them.
Option B - These clients feel helpless and uncomfortable when alone and don't show interest in solitary activities.
Option C - They also pursue relationships in order to have someone to take care of them.
Option D - Although clients with dependent personality disorder may become depressed and suicidal if their
needs aren't met, this isn't a typical response.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 366-367
84. The nurse is assigned to care for a client with dependent personality disorder. Which intervention should the
nurse include in this client's care plan to promote independence?
a. Spending long periods of unscheduled time with the client
b. Scheduling competitive activities so the client can test skills
c. Helping the client identify preferences, such as choosing which clothing item to wear
d. Avoiding discussing the client's feelings of helplessness
ANSWER: C
This intervention promotes development of independent decision-making skills, which the client with dependent
personality disorder lacks. To demonstrate that the nurse is available during set times in a structured
relationship, the nurse should spend scheduled, not unscheduled, time with the client and should set limits on the
amount of time spent. Activities in which the client can succeed would be more appropriate than competitive
ones, which this client would find too threatening. To promote rapport and convey empathy, the nurse should
acknowledge the client's helpless feelings, not avoid discussing them.
85. Personality disorders are diagnosed when personality traits become inflexible and maladaptive and
significantly interfere with how a person functions in society or cause the person emotional distress. Personality
disorders are found on which axis in the DSM-IV-TR?
a. I
b. II
c. III
d. IV
ANSWER: B
The personality disorders are placed on Axis II, apart from other psychiatric disorders. Clinical disorders would be
on Axis I. Medical conditions are placed on Axis III. Axis IV involves psychosocial problems and conditions.
Reference: Deborah Antai-Otong. Psychiatric Nursing: Biological and Behavioral Concepts 2nd edition
86. A client with a borderline personality disorder has been playing one staff member against another. In
formulating a care plan for this client, the nursing staff should include which intervention?
a. Avoiding setting limits
b. Rotating staff members who work with the client
c. Assigning the same staff members to work with the client
d. Avoiding interaction with the client until splitting behaviors stop
ANSWER: B
Rotating staff members who care for a client with borderline personality disorder reduces the incidence of
splitting behaviors. Helping the client to learn to relate to several staff members may reduce fears of
abandonment. The staff should set limits on unacceptable behaviors; the client doesn't have the self-control to
set his own limits. Avoiding the client won't reduce splitting behaviors. The client needs to interact with staff
members to develop relationships and reduce fears of abandonment.
Reference: Videbeck, S.L. Psychiatric Mental Health Nursing 4th Edition
87. A client with borderline personality disorder who has transient psychotic episodes involving auditory
hallucinations is being discharged to home. Which of the following instructions by the nurse is appropriate for
helping the client deal with these episodes?
a. “Call the clinic and ask to speak to someone.”
c. Tell yourself, “I'm not really hearing anything.”
b. “Take additional doses of medication until the voices subside.”
d. “Try to sit quietly until the voices subside.”
ANSWER: A
The client’s physical safety is always a priority. Self-injury can occur when a client is enraged or experiencing
dissociative episodes or psychotic symptoms. Telling the client to call the clinic will determine if the client has
suicidal ideations. The nurse must always seriously consider suicidal ideation with the presence of a plan, access
to means for enacting the plan, and self-harm behaviors and institute appropriate interventions.
Reference: Videbeck, S.L. Psychiatric Mental Health Nursing 4th Edition
88. The nurse is working with a client with antisocial personality disorder. This client's desire to do everything for
himself is based on which of the following?
a. Belief in his own self-worth
c. Rewards for competitive behavior
b. Inability to delay gratification
d. Sense of mistrust of others
ANSWER: C
Clients do not experience disordered thoughts, but their view of the world is narrow and distorted. Because
coercion and personal profit motivate them, they tend to believe that others are similarly governed. They view
the world as cold and hostile and, therefore, rationalize their behavior. Clichés such as, “It’s a dog-eat-dog
world,” represent their viewpoint. Clients believe that they are only taking care of themselves because no one
else will. Their behavior is determined primarily by what they want, and they perceive their needs as immediate.
In addition to seeking immediate gratification, these clients also are impulsive.
Reference: Videbeck, S.L. Psychiatric Mental Health Nursing 4th Edition
89. A 40-year-old male patient with antisocial personality disorder boasts to Nurse Lita about his counseling
abilities. He also says he is starting a relationship with a 17-year-old girl who was recently admitted to the
psychiatric unit. When Nurse Lita expresses concern about this, he accuses Nurse Lita of being aggressive and
threatens to get the nurse Lita in trouble for prying. Which response by Nurse Lita would be most appropriate?
a. "You know better than to threaten me like that."
b. "Leave the other clients alone. We'll work with them."
c. "That girl is too young for a relationship with you. I know you don't want to hurt her, and I trust you to do
what is right."
d. "If you continue to spend time with her, you will be restricted from the activities area."
ANSWER: D
A client with antisocial personality disorder responds best when given specific limits and told of the consequences
of violating these limits. This client doesn't respond well to real or implied threats (option a) or orders (option b).
An antisocial client also doesn't acknowledge a responsibility to comply with social norms and can't be convinced
to do the "right" thing (option c).
90. When assessing a client with narcissistic personality disorder, the nurse would expect the client to
demonstrate which of the following?
a. Genuine concern for others
c. Grandiose and superior self-concept
b. Mistrust of others
d. Dependence on others for decision making
ANSWER: C
Narcissistic personality disorder is characterized by a pervasive pattern of grandiosity (in fantasy or behavior),
need for admiration, and lack of empathy.
Reference: Videbeck, S.L. Psychiatric Mental Health Nursing 4th Edition
91. When planning care for a client with passive-aggressive personality disorder, the nurse will need to include
interventions for which of the following behaviors?
a. Avoidance of anxiety-provoking situations
c. Dependence on others for decisions
b. Compulsive needs for perfection and praise
d. Procrastination and intentional inefficiency
ANSWER: D
Passive-aggressive personality disorder is characterized by a negative attitude and a pervasive pattern of passive
resistance to demands for adequate social and occupational performance. They habitually resent, oppose, and
resist demands to function at a level expected by others. This opposition occurs most frequently in work
situations but also can be evident in social functioning. They express such resistance through procrastination,
forgetfulness, stubbornness, and intentional inefficiency especially in response to tasks assigned by authority
figures.
Reference: Videbeck, S.L. Psychiatric Mental Health Nursing 4th Edition
92. Nurse Sara is assigned to care for a client with dependent personality disorder. Which intervention should
Nurse Sara include in this client's care plan to promote independence?
a. Assisting the client identify preferences, such as choosing which clothing item to wear
b. Spending long periods of unscheduled time with the client
c. Scheduling competitive activities so the client can test skills
d. Avoiding discussing the client's feelings of helplessness
ANSWER: A
This intervention promotes development of independent decision-making skills, which the client with dependent
personality disorder lacks. To demonstrate that the nurse is available during set times in a structured
relationship, the nurse should spend scheduled, not unscheduled, time with the client and should set limits on the
amount of time spent. Activities in which the client can succeed would be more appropriate than competitive
ones, which this client would find too threatening. To promote rapport and convey empathy, the nurse should
acknowledge the client's helpless feelings, not avoid discussing them.
93. Nurse Kekay is working with a client who has a diagnosis of obsessive-compulsive personality disorder. It is
important for Nurse Kekay and client to talk about:
a. The need to feel superior
c. The consequence of anger on perfectionism
b. The need for medication
d. The link between anxiety and perfectionism
ANSWER: D
The person with obsessive-compulsive personality disorder strives at all times to keep the world predictable and
organized. These individuals suffer from excessive fear and anxiety. Anger is not a prominent characteristic of
obsessive-compulsive personality disorder. Medications are not a first line of treatment for personality disorders.
Feelings of superiority are associated with narcissistic personality disorder.
Reference: Kneisl. Contemporary Psychiatric Mental Health Nursing 2nd edition
94. The nurse is preparing to assess a client with a diagnosis of paranoid personality disorder. What client
characteristics will the nurse expect to observe?
a. Superficial charm
b. Grandiosity
c. Affective instability
d. Suspicions and
rigidity
Answer: D
The major features of cluster A disorders are pervasive distrust, social detachment, and subsequent impairment
in social and occupational functioning. Individuals with paranoid personality disorder are inflexible in their
perception of the world. Affective instability, grandiosity, and superficial charm would be characteristic of cluster
B diagnoses.
Reference: Kneisl. Contemporary Psychiatric Mental Health Nursing 2nd edition
95. Nurse Isip is working with a client who has a diagnosis of paranoid personality disorder. Which of the
following things must Nurse Isip be most attentive to at all times?
a. Offering choices
b. Keeping her word
c. Nonverbal behaviors
d. Confronting manipulative behavior
ANSWER: B
While the other choices listed are important, it is the keeping of the nurse's word that is most important with the
client who has paranoid personality disorder. Keeping one’s word facilitates trust in a relationship. The person
with a paranoid personality disorder will hopefully be able to learn to trust others if they are able to build a
trusting relationship with the nurse.
Reference: Deborah Antai-Otong. Psychiatric Nursing: Biological and Behavioral Concepts 2nd edition
96. A client chronically complains of being unappreciated and misunderstood by others. She is argumentative and
sullen. She always blames others for her failure to complete work assignments. She expresses feelings of envy
toward people she perceives as more fortunate. She voices exaggerated complaints of personal misfortune. The
client most likely suffers from which personality disorder?
a. Dependent personality
c. Avoidant personality disorder
b. Passive-aggressive personality
d. Obsessive-compulsive disorder
ANSWER: B
The client with passive-aggressive personality disorder displays a pervasive pattern of negative attitudes, chronic
complaints, and passive resistance to demands for adequate social and occupational performance. The client with
a dependent personality is unable to make everyday decisions and allows others to make important decisions. In
addition, the client with a dependent personality often volunteers to do things that are unpleasant so that others
will like him. The avoidant personality displays a pervasive pattern of social discomfort, fear of negative
evaluation, and timidity. The obsessive-compulsive personality displays a pervasive pattern of perfectionism and
inflexibility.
97. Mr. Bok, a 42-year-old with antisocial personality disorder, brags to the nurse about his counseling abilities.
He also says he is starting a relationship with a 15-year-old girl who was recently admitted to the psychiatric
unit. When the nurse expresses concern about this, he accuses the nurse of being hostile and threatens to get
the nurse in trouble for interfering. Which response by the nurse would be most appropriate?
a. "You know better than to threaten me like that."
b. "Leave the other clients alone. We'll work with them."
c. "That girl is too young for a relationship with you. I know you don't want to hurt her, and I trust you to do
what is right."
d. "If you continue to spend time with her, you will be restricted from the activities area."
ANSWER: D
A client with antisocial personality disorder responds best when given specific limits and told of the consequences
of violating these limits. This client doesn't respond well to real or implied threats (option a) or orders (option b).
An antisocial client also doesn't acknowledge a responsibility to comply with social norms and can't be convinced
to do the "right" thing (option c).
98. A 22-year-old client has been diagnosed with antisocial personality disorder. She has been having problems
since age 15, when she ran away from home. She has had two broken marriages, has been unable to keep a job
for more than 2 months, and has had difficulties with the law because she has abused drugs and passed bad
checks. Although the client has made all the telephone calls she is allowed for the day, she asks the nurse, "Can't
I just make one more phone call?" Which response by the nurse would be best?
a. "Okay, but don't talk too long."
b. "Okay, if you promise to obey the rules the rest of the day
c. "No, you can't. The rules apply equally to everyone, and you are asking to break them."
d. "No, you can't. Go watch television."
ANSWER: C
This response enforces the limits and explains why the client can't use the phone.
Options A and B - don't encourage the client to follow the rules.
Option D - doesn't explain why the client's request is being denied.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 354-356
99. During an initial assessment, a client reports the following behaviors: social inhibition, hypersensitivity to
negative evaluation, fear of criticism, and social ineptitude. The nurse suspects which of the following personality
disorders?
a. Narcissistic
b. Antisocial
c. Paranoid
d. Avoidant
ANSWER: D
The behaviors describe avoidant behaviors.
Option B - Antisocial behaviors are against society but aren't inhibited.
Option A and C - Paranoid behaviors are those in which a client is suspicious of the actions of others, and
narcissistic are self-centered behaviors.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 366
100. The nurse would assess for which of the following characteristics of a client with a narcissistic personality
disorder?
a. Entitlement
b. Fear of abandonment
c. Hypersensitivity
d. Suspiciousness
ANSWER: A
Narcissistic personality disorder is characterized by a pervasive pattern of grandiosity (in fantasy or behavior),
need for admiration and lack of empathy. They often display a sense of entitlement or unrealistic expectation of
special treatment or automatic compliance with wishes.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 395
30. A client is being admitted to the mental health unit with a diagnosis of cluster A personality disorder. The
nurse assesses this client for behavior that is:
a. Anxious and fearful
c. Manipulative and dramatic
b. Characterized by anger
d. Suspicious and eccentric
ANSWER: D
Clients with cluster A personality disorders often behave in a manner that is odd or eccentric. Suspicion of others
is particularly typical in paranoid personality disorder, a cluster A disorder. Manipulative and dramatic behaviors
are typical of some of the cluster B disorders. Anger, anxiety, and fearfulness are typical of clients with cluster C
disorders.
Note: Cluster A personality disorders (odd and eccentric – paranoid, schizoid and schizotypal personality
disorders)
MENTAL HEALTH AND PSYCHIATRIC NURSING
SCHIZOPHRENIA
SITUATION: The nurse encounters several clients with marked difficulties in thought process and content.
1. While the nurse is assisting a client with the diagnosis of schizophrenia with morning care, the client suddenly
throws off covers and starts shouting, “My body is disintegrating; I am being pinched.” The term that best
describes the client’s behavior is:
a. Paranoid ideation
b. Depersonalization
c. Looseness of association
d. Idea of reference
ANSWER: B
This is an example of depersonalization. The client may describe feelings of being disconnected from himself or
herself during periods of psychosis. Looseness of association is a disorganized thinking that jumps from one idea
to another with little or no evident relation between thoughts. Idea of reference is a client’s inaccurate
interpretation of general events that are personally directed to him or her such as hearing s speech on the news
and believing the message had a personal meaning.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 310
2. The verbalizations of a client with schizophrenia may contain words that sound like the client is speaking a
different language. The nurse recognizes that this communication is an example of:
a. Clanging
b. Echolalia
c. Neologisms
d. Echopraxia
ANSWER: C
This communication is an example of neologisms where a client use invented words that only have meaning to
him or her. Clanging or clang associations are the use of rhyming words in a sentence that makes no sense.
Echolalia is repetition or imitation of what someone else says while echopraxia is the imitation of movements or
gestures the client is observing.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 308
3. A client reports “there are rats eating my brain”. This is an example of which type of delusion?
a. Paranoid
b. Referential
c. Somatic
d. Grandiose
ANSWER: C
Somatic delusions are generally vague and unrealistic beliefs about the client’s health or bodily functions. Factual
information or diagnostic tests do not change these beliefs.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 309
4. A client is admitted to the psychiatric unit with active psychosis. The physician diagnoses schizophrenia after
ruling out several other conditions. Schizophrenia is characterized by:
a.
loss
of
identity
and
self-esteem.
b.
multiple
personalities
and
decreased
self-esteem.
c.
disturbances
in
affect,
perception,
and
thought
content
and
form.
d. persistent memory impairment and confusion.
ANSWER: C
The Diagnostic and Statistic Manual of Mental Disorders, 4th edition, defines schizophrenia as a disturbance in
multiple psychological processes that affects thought content and form, perception, affect, sense of self, volition,
relationship to the external world, and psychomotor behavior. Loss of identity sometimes occurs but is only one
characteristic of the disorder. Multiple personalities typify multiple personality disorder, a dissociative personality
disorder. Mood disorders are commonly accompanied by increased or decreased self-esteem. Schizophrenia
doesn't cause a disturbance in sensorium, although the client may exhibit confusion, disorientation, and memory
impairment during the acute phase.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 299
5. Positive symptoms of schizophrenia include which of the following:
a. hallucinations, delusions, and disorganized thinking
c. waxy flexibility, alogia, and apathy
b. somatic delusions, echolalia, and a flat affect
d. flat affect, avolition, and anhedonia
ANSWER: A
The positive symptoms of schizophrenia are distortions of normal functioning. Option A lists the positive
symptoms of schizophrenia. A flat affect, alogia, apathy, avolition, and anhedonia refer to the negative
symptoms. Negative symptoms list the diminution or loss of normal function.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 297
6. The client is having negative symptoms associated with his illness. Which of the following is classified as a
negative symptom?
a. Hallucinations
b. Blunted affect
c. Ideas of reference
d. Delusions
ANSWER: B
Negative symptoms of schizophrenia indicate a loss or lack of normal functioning. They develop over time and
hinder the individual’s ability to endure life tasks. Examples of the negative symptoms are: (The A’s) Anhedonia,
alogia, anergia, avolition, ambivalence and Affect (disturbance). Options A, C and D are all positive signs of
schizophrenia.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 297
7. A 28-year-old male was diagnosed with schizophrenia disorganized type and is admitted to the psychiatric
unit. His behaviour is very regressed and infantile. He openly defecates and masturbates on the floor. The best
initial action for the nurse with this client early in his hospitalization is to:
a. Assist him to modify his behaviour by establishing unit rules
b. Ignore his behaviour until he adjusts to the unit routines
c. Insist that he clean up his own feces and use the bathroom to masturbate
d. Convey acceptance of the client in spite of his age inappropriate behavior
ANSWER: D
Trust is conveyed through acceptance of this client as a person in spite of this behavior.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 313
8. A client informed the nurse that there were spies that have bugged her room. The most appropriate response
by the nurse to this delusional material is:
a. “Tell me more about the spies. I’d like to hear about it”
b. “It is impossible that they would spy on you”
c. “Let’s sit down and talk. You probably feel frightened about this”
d. Let’s go check your room. I’m sure we won’t find any bugs
ANSWER: C
In responding to the delusional clients, the nurse should state his/her intent and empathize with the feeling tone
of the delusional client. The nurse should not argue with the client’s delusion or reinforce the client’s delusion.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 314
9. A client with schizophrenia tells the nurse that “the voices are frightening me”. The nurse’s best response is:
a. “I’ll report this to your doctor”
b. “I don’t hear the voices that you hear but I understand that you are frightened”
c. “You know, you’re not really hearing anything
d. “Nothing will hurt you. I promise you that
ANSWER: B
In responding to a client with hallucination, the nurse should reinforce reality, assess the nature of the
hallucination and interrupt the hallucinatory cycle.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 314
10. A client presents in the intake assessment office of the mental health clinic with mutism and wax-like
flexibility of the extremities. What type of schizophrenia is characteristic of these findings?
a. Disorganized type
b. Undifferentiated type
c. Residual type
d. Catatonic type
ANSWER: D
Clients with catatonic-type schizophrenia may exhibit mutism and wax-like flexibility of the extremities. The
mutism and wax-like flexibility of the extremities are not characteristic of the other diagnoses (options A, B, and
C).
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 307
11. A 60-year-old client is taking chlorpromazine (Thorazine) 50 mg po qid for a few years now. A few days ago,
the client was admitted to the hospital and the dose was increased to 75 mg po qid. The nurse makes all the
following observations. Which one would be of the greatest concern to the nurse?
a. The client complains of pain and stiffness in her neck and face
b. The client experiences an episode of dizziness and orthostatic hypotension
c. The client says that she has trouble staying awake during the day
d. The client has rhythmic, fine vermicular movements of the tongue
ANSWER: D
Vermicular tongue movements may indicate the onset of tardive dyskinesia which is difficult to treat and often
irreversible if allowed to progress. This is usually irreversible after it has developed although decreasing or
discontinuing antipsychotic medications can arrest its progression. Her physician may have to discontinue the
medication.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 29
12. A client taking antipsychotic medications for treatment of schizophrenia complains to the nurse of feeling
nervous. The nurse notices that the client is pacing the long hallway and is unable to remain still even when other
clients are talking with him. This client is most likely experiencing:
a. Akathisia.
b. Akinesia.
c. Dystonia.
d. Tardive dyskinesia.
ANSWER: A
Akathisia is an extrapyramidal side effect of antipsychotic medications that may manifest as subjective and
objective restlessness. Akinesia (option B), dystonia (option C), and tardive dyskinesia (option D) are also
extrapyramidal side effects of antipsychotic medications, but are not characteristic of this client’s symptoms.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 304
13. Which information is most important for the nurse to include in a teaching plan for a schizophrenic client
taking clozapine (Clozaril)?
a. Monthly blood tests will be necessary.
b. Report a sore throat or fever to the physician immediately.
c. Blood pressure must be monitored for hypertension.
d. Stop the medication when symptoms subside.
ANSWER: B
A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening
complication of clozapine therapy. Because of the risk of agranulocytosis, white blood cell (WBC) counts are
necessary weekly, not monthly. If the WBC count drops below 3,000/µl, the medication must be stopped.
Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness
from orthostatic hypotension. The medication should be continued, even when symptoms have been controlled. If
the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of
a physician.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 305
Reference: Springhouse Nurse’s Drug Guide. (2005) 6th edition. Lippincott Williams and Wilkins
SITUATION: Mike, a 33-year-old divorced man, has two children ages 8 and 10, which he rarely ever sees. He
has never been seen by a psychiatrist. His family physician has tried to get him see a local psychiatrist but Mike
refuses to go. Mike says he knows someone has removed his brain and replaced it with someone else's. He
believes that the brain is controlling him and that he is not responsible for his actions. He hears voices. He works
everyday and has been on his current job for 15 years. He says he has lots of friends but sometimes he thinks
it’s one of them who did this to him.
14. Based on initial assessment of Nurse Gener, Mike is suffering from what psychiatric disorder?
a. Bipolar disorder
b. Schizophrenia
c. Paraphilia
d. Seasonal Affective Disorder
ANSWER: B
The presence of delusions and auditory hallucinations confirm diagnosis of schizophrenia. Option A: Bipolar
disorder is affective or mood disorder characterized by at least one episode of mania, with or without a history of
depression. Option C: Paraphilia is a condition in which the sexual instinct is expressed in ways that are socially
prohibited or unacceptable or are biologically undesirable. Option D: SAD is a depression occurring in conjunction
with seasonal change most often beginning in fall or winter and remitting in spring.
Reference. Norman Keltner. Psychiatric Nursing. 5th edition. Page 342, 371, 487-489
15. Schizophrenia typically occurs in what stage of life?
a. Pre-school
b. Middle adulthood
c. Adolescence
d. Late adulthood
ANSWER: C
Schizophrenia typically occurs in adolescence or early adulthood, a time during brain maturation is almost
complete.
Reference. Norman Keltner. Psychiatric Nursing. 5th edition. Page 341
16. According to the Biochemical theory of schizophrenia hypothesis, treatment is directed towards correcting the
chemical imbalance. Which neurotransmitter would the nurse identify as the target of antipsychotic medications?
a. Dopamine
b. Serotonin
c. Acetylcholine
d. Norepinephrine
ANSWER: A
According to dopamine hypothesis, excessive dopaminergic activity in limbic areas causes acute positive
symptoms of schizophrenia. Option B and D: decreased level of serotonin and norepinephrine causes depression.
Option C: imbalance of this neurotransmitter cause Parkinson’s disease.
Reference. Norman Keltner. Psychiatric Nursing. 5th edition. Page 205, 349.
17. Nurse Gener notices Mike to be listening to someone who isn't discernible. Without warning, he would shout
angrily and would then abruptly stop. Which nursing intervention is the most appropriate?
a. Approach Mike and tap him to get his attention.
b. Encourage Mike to go to his room to avoid distractions.
c. Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices.
d. Ask the client to describe what the voices are saying.
ANSWER: C
By acknowledging that the client hears voices, the nurse conveys acceptance of the client. By letting the client
know that the nurse doesn't hear the voices, the nurse avoids reinforcing the hallucination. The nurse shouldn't
touch the client with schizophrenia without advance warning. The hallucinating client may believe that the touch
is a threat or act of aggression and respond violently. Being alone in his room encourages the client to withdraw
and may promote more hallucinations. The nurse should provide an activity to distract the client. By asking the
client what the voices are saying, the nurse is reinforcing the hallucination. The nurse should focus on the client's
feelings, rather than the content of the hallucination.
Reference. Norman Keltner. Psychiatric Nursing. 5th edition. Page 357-358
18. Mike tells Nurse Gener that the Actress in the teleserye is sending a secret message to him. Nurse Gener
suspects
that
Mike
is
experiencing
which
of
the
following?
a. A delusion
b. Flight of ideas
c. Delusions of reference
d. A hallucination
ANSWER:
C
Delusions of reference: Everything occurring in environment has direct significance to oneself, like thinking that
the actress is sending him a secret message. A delusion is a false belief. Flight of ideas is a speech pattern in
which the client skips from one unrelated subject to another. A hallucination is a sensory perception, such as
hearing voices and seeing objects, that only the client experiences.
Reference. Norman Keltner. Psychiatric Nursing. 5th edition. Page 348
19. Which of the following is the best response to a client with paranoid schizophrenia who makes remarks like
"How
do
I
know
if
that
is
really
my
pills?"
a.
Say,
"You
know
this
is
your
medicine."
b.
Allow
him
to
open
the
individual
wrappers
of
the
medication.
c.
Say,
"Don't
worry
about
what
is
in
the
pills.
It's
what
is
ordered."
d.
Ignore
the
comment
because
it's
probably
a
joke.
ANSWER: B
Option B is correct because allowing a paranoid client to open his medication can help reduce suspiciousness.
Explain any treatments, medications and laboratory tests before initiating them. Option A is incorrect because the
client doesn't know that it's his medication and he's obviously suspicious. Telling the client not to worry or
ignoring the comment isn't supportive and doesn't offer reassurance.
Reference: Ann Isaacs. Mental Health and Psychiatric Nursing. 4th edition. Page 131
20. The nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoid
schizophrenia.
Which
nursing
diagnosis
should
receive
the
highest
priority?
a. Risk for violence toward self or others
c.
Ineffective
family
coping
b. Imbalanced nutrition: Less than body requirements
d. Impaired verbal communication
ANSWER:
A
Because of such factors as suspiciousness, anxiety, and hallucinations, the client with paranoid schizophrenia is
at risk for violence toward himself or others. The other options are also appropriate nursing diagnoses but should
be addressed after the safety of the client and those around him is established.
Reference.
Norman
Keltner.
Psychiatric
Nursing.
5th
edition.
Page
360
21. The nurse is preparing a client for the discharge who has been hospitalized for paranoid schizophrenia. The
client's husband expresses concern whether his wife should still continue to take her daily prescribed medication.
The
nurse
should
inform
him
that:
a. His concern is valid but his wife is an adult and has the right to make her own decisions.
b.
He
can
easily
mix
the
medication
in
his
wife's
food
if
she
stops
taking
it.
c. His wife can be given a long-acting medication that is administered every 1 to 2 weeks.
d. His wife knows she must take her medication as prescribed to avoid future hospitalizations.
ANSWER: C
If a client is non compliant, expect to administer the antipsychotic drug IM. Fluphenazine decanoate (Prolixin)
may be administered every 1 to 2 weeks, Haloperidol decanoate is usually administered every 2 to 4 weeks, and
Risperidone (Risperdal) is administered every 2 weeks to clients who are non compliant regarding us of
prescribed medication. A client has the right to refuse medication, but this issue isn't the focus of discussion at
this time. Medication should never be hidden in food or drink to trick the client into taking it; besides destroying
the client's trust, doing so would place the client at risk for overmedication or undermedication because the
amount administered is hard to determine. Assuming the client knows she must take the medication to avoid
future
hospitalizations
would
be
unrealistic.
Reference: Louise Shives. Psychiatric Mental Health Nursing. 7th edition. Page 226
22. A client has been receiving chlorpromazine (Thorazine), to treat his psychosis. Which findings should alert the
nurse
that
the
client
is
experiencing
pseudoparkinsonism?
a.
Restlessness,
difficulty
sitting
still,
and
pacing
b.
Involuntary
rolling
of
the
eyes
c.
Tremors,
bradykinesia,
and
rigidity
d.
Extremity
and
neck
spasms,
facial
grimacing,
and
jerky
movements
ANSWER: C
Pseudoparkinsonism generally occurs after first week of treatment or before second month. Akathisia may occur
2 weeks after starting antipsychotic therapy and consists of restlessness, difficulty sitting still, and fidgeting. An
oculogyric crisis is recognized by uncontrollable rolling back of the eyes and, along with dystonia, should be
considered an emergency. Dystonia may occur minutes to hours after receiving an antipsychotic and may include
extremity
and
neck
spasms,
jerky
muscle
movements,
and
facial
grimacing.
Reference: Louise Shives. Psychiatric Mental Health Nursing. 7th edition. Page 224
23. A client with chronic schizophrenia, who is receiving 10 mg of fluphenazine hydrochloride (Prolixin) P.O. four
times a day, suddenly develops a temperature of 102° F (38.9° C), a heart rate of 120 beats/minute, a
respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mm Hg. The nurse suspects Neuroleptic
Malignant
Syndrome.
Which
of
the
following
the
nurse
should
do
first?
a.
Give
the
next
dose
of
fluphenazine,
call
the
physician,
and
monitor
vital
signs.
b. Withhold the next dose of fluphenazine, call the physician, and monitor vital signs.
c. Give the next dose of fluphenazine and restrict the client to the room to decrease stimulation.
d. Withhold the next dose of fluphenazine, administer an antipyretic agent, and increase the client's fluid intake.
ANSWER: B
NMS is a dangerous adverse effect of antipsychotic drugs such as fluphenazine. The nurse should discontinue the
drug the next dose, notify the physician, and continue to monitor vital signs. Although an antipyretic agent may
be used to reduce fever, increased fluid intake is contraindicated because it may increase the client's fluid volume
further, raising blood pressure even higher.
Reference: Louise Shives. Psychiatric Mental Health Nursing. 7th edition. Page 225
Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 221
24. The neuroleptic malignant syndrome was resolved and the client will resume taking the prescribed
antipsychotic medication. Which of the following statement, if made by the client, would indicate an
understanding of the resumption of antipsychotic medications?
a. “After three days I will resume my medication”
c. “I can restart my medication after 2 to 3 weeks”
b. “Immediately after the resolution of NMS’
d. “I can resume anytime I feel like taking the medications”
ANSWER: C
Antipsychotics should not be reinstituted for at least 2 weeks after complete resolution of NMS.
Reference:Norman Keltner. Psychiatric Nursing. 5th edition. Page 221
25. The nurse is caring for a client with schizophrenia. Which of the following outcomes is the least desirable?
a.
The
client
spends
more
time
by
himself.
b.
The
client
doesn't
engage
in
delusional
thinking.
c.
The
client
doesn't
harm
himself
or
others.
d.
The
client
demonstrates
the
ability
to
meet
his
own
self-care
needs.
ANSWER: A
The client with schizophrenia is commonly socially isolated and withdrawn; therefore, having the client spend
more time by himself wouldn't be a desirable outcome. Rather, a desirable outcome would specify that the client
spend more time with other clients and staff on the unit. Delusions are false personal beliefs. Reducing or
eliminating delusional thinking using talking therapy and antipsychotic medications would be a desirable
outcome. Protecting the client and others from harm is a desirable client outcome achieved by close observation,
removing any dangerous objects, and administering medications. Because the client with schizophrenia may have
difficulty meeting his or her own self-care needs, fostering the ability to perform self-care independently is a
desirable
client
outcome.
Reference: Ann Isaacs. Mental health and Psychiatric Nursing.4th edition. Page 131
26. A client diagnosed with schizophrenia is displaying flat affect, slowed thinking and a lack of motivation. The
nurse interprets these as which of the following?
a. Delusions
b. Positive symptoms
c. Hallucination
d. Negative symptoms
ANSWER: D
Negative symptoms such as flattened affect, slowed thinking and lack of motivation are observed and in many
ways are more debilitating Unlike positive clinical manifestations, negative symptoms are behaviors
fundamentally different from behaviors exhibited by many people. They are more common and severe in
schizophrenia. They are particularly obvious when contrasted to how the client was before the onset of the
disorder. Delusions and hallucinations are positive symptoms because they must be self reported by the client.
Reference:Norman Keltner. Psychiatric Nursing. 5th edition. Page 342-343
SITUATION: Schizophrenia is a mental disorder characterized by a disintegration of the process of thinking and
of emotional responsiveness.
27. Which behaviors would the nurse most likely assess in a client with a diagnosis of disorganized schizophrenia?
a. Absence of acute symptoms, impaired role function
b Extreme social withdrawal, odd mannerisms and behaviors
c. Psychomotor immobility, presence of waxy flexibility
d. Suspiciousness toward others, increased hostility
ANSWER: B
Disorganized schizophrenia is characterized by regressive behavior with extreme social withdrawal and frequently
odd mannerisms. The absence of acute symptoms and impaired role function are more 'characteristic of residualtype schizophrenia.
Psychomotor immobility and presence of waxy flexibility are more indicative of catatonic
schizophrenia. Suspiciousness toward others and increased hostility is more characteristic of paranoid
schizophrenia.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
28. In planning care for a client with schizophrenia who has negative symptoms, Nurse Isabelle would anticipate
a problem with:
a. Auditory hallucinations
b. Bizarre behaviors
c. Ideas of reference
d. Motivation for activities
ANSWER: D
In a client demonstrating-negative symptoms of schizophrenia, avolition, or the lack of motivation for activities,
is a common problem. All of the other symptoms listed are the positive symptoms of schizophrenia.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
29. The family of a schizophrenic client asks the nurse if there is a genetic cause of this disorder. To answer the
family, which fact would the nurse cite?
a. Conclusive evidence indicates a specific gene transmits the disorder.
b. Incidence of this disorder is variable in all families.
c. There is little evidence that genes play a role in transmission.
d. Genetic factors can increase the vulnerability for this disorder.
ASNWER: D
Research shows that family history statistically increases the risk for development of schizophrenia. However no
single gene has yet been identified. Options 2 and 3 are both incorrect because genetics plays a role in the
etiology of schizophrenia.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
30. Which of the following nursing interventions would be most appropriate for a client with schizophrenia,
paranoid type?
a. Establishing a non-demanding relationship
c. Spending more time with the client
b. Encouraging involvement in group activities
d. Waiting until the client initiates interaction
ASNWER: A
A nonthreatening non-demanding relationship helps decrease the mistrust that is common in a client with
paranoid schizophrenia. Encouraging involvement in group activities and spending more time with the client
would be threatening for a client who is suspicious of other people's motives. This client is unlikely to initiate
interaction; the nurse is responsible for initiating a relationship with the client.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
31. A client tells the nurse that psychotropic medicines are dangerous and refuses to take them. Which
intervention should the nurse use first?
a. Ask the client about any previous problems with psychotropic medications
b. Ask the client if an injection is preferable
c. Insist that the client take medication as prescribed
d. Withhold the medication until the client is less suspicious
ANSWER: A
The nurse needs to clarify the client's previous experience with psychotropic medication in order to understand
the meaning of the client's statement. Asking the client if an injection is preferable may add to the client's
suspicion and feeling threatened. Withholding medication prescribed to relieve delusional beliefs will likely
intensify paranoid thinking, Insisting that the client take medication can be a violation of his right to refuse
treatment.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
32. Upon a client's admission for acute psychiatric hospitalization, Nurse Isabelle documents the following: client
refuses to bathe or dress, remains in room most of the day; speaks infrequently to peers or staff. Which nursing
diagnosis would be the priority at this time?
a. Anxiety
b. Decisional conflict
c. Self-care deficit
d. Social isolation
ANSWER: D
These behaviors indicate the client's withdrawal from others and possible fear or mistrust of relationships. There
is no indication of Anxiety or Decisional conflict in the information provided. Although the client refuses to bathe
or dress, Self-care deficit would not be the priority nursing diagnosis in this situation.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
33. Which statement is correct about a 25- year-old client with newly diagnosed schizophrenia?
a. Age of onset is typical for schizophrenia
c. Age of onset is earlier than usual for schizophrenia.
b. Age of onset is later than usual for schizophrenia.
d. Age of onset follows no predictable pattern in schizophrenia
ANSWER: A
The primary age of onset for schizophrenia is late adolescence through young adulthood (ages 17 to 27).
Paranoid schizophrenia may sometimes have a later onset. All of the other options are incorrect.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
34. Which factor is associated with increased risk for schizophrenia?
a. Alcoholism
b. Adolescent pregnancy
c. Overcrowded schools
d. Poverty
ANSWER: D
Low socioeconomic status or poverty is an identified environmental factor associated with increased incidence of
schizophrenia. Although alcoholism, adolescent pregnancy, and overcrowded schools may be stressful. research
does not show they increase the risk for schizophrenia.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
35. A client is admitted to a psychiatric facility with a diagnosis of chronic schizophrenia. The history indicates
that the client has been taking neuroleptic medication for many years. Assessment reveals unusual movements
of the tongue, neck, and arms. Which condition should the nurse suspect?
a. Tardive dyskinesia
b. Dystonia
c. Neuroleptic malignant syndrome
d. Akathisia
ANSWER: A
Unusual movements of the tongue, neck, and arms suggest tardive dyskinesia, an adverse reaction to neuroleptic
medication. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles.
Neuroleptic malignant syndrome causes rigidity, fever, hypertension, and diaphoresis. Akathisia causes
restlessness, anxiety, and jitteriness.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
36. A client with a history of noncompliance to medication therapy is receiving outpatient treatment for chronic
undifferentiated schizophrenia. The doctor is most likely to prescribe which medication for this client?
a. Thorazine
b. Tofranil
c. Prolixin Decanoate
d. Lithane
ANSWER: C
Fluphenazine decanoate is a long-acting antipsychotic agent given by injection. Because it has a 4-week duration
of action, it's commonly prescribed for outpatients with a history of medication noncompliance. Chlorpromazine,
also an antipsychotic agent, must be administered daily to maintain adequate plasma levels, which necessitates
compliance with the dosage schedule. Imipramine, a tricyclic antidepressant, and lithium carbonate, a mood
stabilizer, are rarely used to treat clients with chronic schizophrenia.
Reference: Amy Karch. Focus on Nursing Pharmacology 3rd edition
37. A client with a diagnosis of schizophrenia, paranoid type, is admitted to an acute-care psychiatric hospital
unit. In anticipation of the client’s needs, what nursing diagnosis would be given the highest priority?
a. Altered thought processes
c. Impaired verbal communication
b. Social isolation
d. Risk for violence directed at self or at others
Answer: D
Rationale: Safety is always the highest priority when caring for a client with a diagnosis of schizophrenia,
paranoid type. Clients with this diagnosis are potentially violent and can quickly become aggressive as a result of
their psychosis. The other options (A, B, and C) of diagnoses are appropriate for the client’s care plan but are not
given the highest priority.
38. While working with a client who is having delusions, what nursing intervention would be most helpful?
a. Avoid challenging the content of the client’s delusion.
b. Promise the client that antipsychotic meds will improve thought processes.
c. Challenge the content of the client’s delusion.
d. Seclude the client in his room to decrease stimulation.
Answer: A
Rationale: The client believes that his or her thoughts are true. Challenging the client’s thoughts only increases
anxiety, mistrust, and conflict for the client (option C). Promises should never be made to a client because, if not
kept, trust cannot be established (option B). Seclusion is not an appropriate intervention for delusional thought
processes (option D).
39. A male client diagnosed with schizophrenia is having negative symptoms associated with his illness. Which of
the following is classified as a negative symptom?
a. Abnormal thoughts
b. Ideas of reference
c. Blunted affect
d. Hallucinations
Answer: C
Rationale: A blunted affect is characteristic of a negative symptom of schizophrenia. All the other options are
positive symptoms associated with schizophrenia (options A, B, and D).
40. A female home health client in your care was recently started on a typical antipsychotic medication. While
assessing the client, you notice that the client’s hands are trembling and she complains of muscle stiffness. Her
vital signs indicate hyperthermia and tachycardia. Based on this information, what should you do next?
a. Administer the prn acetaminophen (Tylenol) ordered for the client.
b. Tell the client to rest today and increase her fluid intake.
c. Transport client to the hospital ER for further evaluation.
d. Schedule an appointment with the client’s physician for further evaluation.
Answer: C
Rationale: This client is exhibiting signs and symptoms of neuroleptic malignant syndrome (NMS). This is a
potentially lethal side effect of antipsychotic medications that requires immediate medical care. All the other
interventions are not appropriate and would delay appropriate treatment (option A, B, and D).
41. While meeting with a schizophrenic client’s family, you are asked the question, “What causes schizophrenia?”
The best response to this question is:
a. “Research indicates that schizophrenia is caused by a genetic predisposition.”
b. “The exact cause of schizophrenia is unclear at this time.”
c. “Poor parenting skills most likely caused schizophrenia to occur.”
d. “An early-age trauma most likely caused schizophrenia to occur.”
Answer: B
Rationale: The precise cause of schizophrenia is unknown. The general consensus is that schizophrenia results
from the interaction between factors that have been correlated with schizophrenia. Research has correlated
genetic factors with schizophrenia, but more research is needed (option A). Poor parenting skills (option C) or
early-age trauma (option D) have not been documented in causing schizophrenia.
42. While working with a client who is withdrawn and disconnected, which of the following is an appropriate
short-term goal? The client will:
a. Attend one group meeting accompanied by a staff member within 1 week.
b. Voluntarily lead the unit community meeting by discharge from the hospital.
c. Be more connected to the unit in 3 days.
d. Attend many of the unit group meetings by discharge from the hospital.
Answer: A
Rationale: Short-term goals need to be measurable and accomplished in a brief period of time. Clients need to
meet short-term goals during hospitalization to promote a sense of accomplishment, which may increase their
self-esteem. Options B, C, and D are less measurable then option 1.
43. A client presents in the intake assessment office of the mental health clinic with mutism and wax-like
flexibility of the extremities. What type of schizophrenia is characteristic of these findings?
a. Disorganized type
b. Undifferentiated type
c. Residual type
d. Catatonic type
Answer: D
Rationale: Clients with catatonic-type schizophrenia may exhibit mutism and wax-like flexibility of the
extremities. The mutism and wax-like flexibility of the extremities are not characteristic of the other diagnoses
(options A, B, and C).
44. The nurse administering atypical antipsychotic medications is aware that they have been defined as having
which of the following characteristics?
a. High risk for tardive dyskinesia
b. Minimal to no risk for extrapyramidal effects
c. Effective in treating only positive symptoms of schizophrenia
d. Effective in treating only negative symptoms of schizophrenia
Answer: B
Rationale: Atypical antipsychotic medications are helpful in treating both negative (option D) and positive (option
C) symptoms of schizophrenia. This class of medications has minimal to no risk for extrapyramidal side effects,
which includes tardive dyskinesia (option A).
45. A male client with a diagnosis of schizophrenia tells you that his roommate is putting thoughts in his mind
against his will. This is an example of:
a. Thought broadcasting.
b. Thought blocking.
c. Thought insertion.
d. Thought control.
Answer: C
Rationale: Thought insertion is a thought disorder of schizophrenia that is defined as the client believing that
others are putting thoughts in his or her mind against the client’s will. Thought broadcasting is the belief by a
client that he or she can broadcast his or her thoughts to others (option A). Thought blocking occurs when a
client’s thoughts stop in midstream (option B). Thought control is the belief that others can control their thoughts
against their will (option D).
46. While talking with a client diagnosed with schizophrenia, you notice the client loses eye contact with you and
starts staring at the wall. The client is making facial grimaces. The most appropriate nursing intervention would
be to:
a. End the conversation because the client is not listening to you.
b. Administer to the client the ordered prn trihexyphenidyl (Artane).
c. Ask the client directly, “What are you seeing on the wall?”
d. Redirect the client’s attention to continue your conversation.
Answer: C
Rationale: This client is most likely experiencing a visual hallucination. First, it is important for nurses to know
the content of the hallucination so they can assist the client to process the experience and prevent any
aggressive behavior. After this intervention is completed, than the client should be oriented back to reality.
Ending the conversation would not promote trust with the client (option A). Trihexyphenidyl will not prevent
hallucinations (option B). The nurse should not redirect the conversation until the nurse has evaluated for
hallucinations (option D).
47. A client taking antipsychotic medications for treatment of schizophrenia complains to the nurse of feeling
nervous. The nurse notices that the client is pacing the long hallway and is unable to remain still even when other
clients are talking with him. This client is most likely experiencing:
a. Akathisia.
b. Akinesia.
c. Dystonia.
d. Tardive dyskinesia.
Answer: A
Rationale: Akathisia is an extrapyramidal side effect of antipsychotic medications that may manifest as subjective
and objective restlessness. Akinesia (option B), dystonia (option C), and tardive dyskinesia (option D) are also
extrapyramidal side effects of antipsychotic medications, but are not characteristic of this client’s symptoms.
48. A client is exhibiting symptoms that are characteristic of schizophrenia, but is also exhibiting manic
behaviors. This client’s most likely diagnosis is:
a. Schizophreniform disorder.
c. Shared psychotic disorder.
b. Brief psychotic disorder.
d. Schizoaffective disorder.
Answer: D
Rationale: Schizoaffective disorder has clinical manifestations that are characteristic of both schizophrenia and a
mood disorder, such as mania, depression, or a mixed episode. Schizophreniform disorder (option A), brief
psychotic disorder (option B), and shared psychotic disorder (option C) have other essential characteristics not
indicative of what this client is exhibiting.
49. A male client on the unit has a diagnosis of paranoid-type schizophrenia. The new mental health care worker
on this unit approaches the nurse and asks about the best way to work with this client. The nurse replies:
a. “Avoid touching this client and invading personal space.”
b. “Offer back rubs at bedtime to decrease the client’s anxiety.”
c. “Greet this client with a firm handshake.”
d. “Place your hand on the client very softly when you speak to him.”
Answer: A
Rationale: Paranoid schizophrenic clients are very suspicious and potentially dangerous. It is best to avoid any
physical contact with a client that has a diagnosis of paranoid schizophrenia because the client may feel
threatened. Offering a back rub (option B), shaking hands (option C), and placing a hand on the client (option D)
include physical contact. Also it is safer to keep a physical distance from the client in the event he becomes
physically aggressive.
50. What nursing diagnosis is most likely to be associated with a client diagnosed as having schizophrenia,
residual type?
a. Impaired verbal communication
b. Self-care deficit
c. Social isolation
d. Anxiety
ANSWER: C
Rationale: Residual-type schizophrenia manifests with socially withdrawn behavior, an inappropriate affect, and
an absence of prominent psychotic symptoms. The most likely and common nursing diagnosis would be Social
isolation. Impaired verbal communication (option A), Self-care deficit (option B), and Anxiety (option D) are less
likely with schizophrenia, residual type.
51. What nursing diagnosis is most likely to be associated with a client diagnosed as having schizophrenia,
disorganized type?
a. Impaired verbal communication
c. Social isolation
b. Sleep pattern disturbance
d. Self-care deficit
ANSWER: A
Rationale: Schizophrenia, disorganized type, is characterized by disorganized speech patterns. Other
manifestations of this diagnosis include disorganized behavior and inappropriate affect. Sleep pattern disturbance
(option B), Social isolation (option C), and Self-care deficit (option D) are possible, but not classic for
disorganized schizophrenia.
52. Which of the following statements is correct in regards to the Abnormal and Involuntary Movement Scale
(AIMS)?
a. The AIMS is used to screen for pseudoparkinsonism.
b. The AIMS should be used yearly to screen clients taking antipsychotic agents.
c. A rating on the AIMS of zero indicates absence of abnormal involuntary movement.
d. The AIMS is a diagnostic tool used to identify tardive dyskinesia.
Answer: C
Rationale: The AIMS is used to screen for signs of tardive dyskinesia, which is a possible side effect of
antipsychotic medications. It is not a screening tool (options A and B) or a diagnostic tool (option D). A score of 1
to 4 on any single item indicates the need for further evaluation. A score of 0 on all items indicates no further
evaluation is needed.
53. A female client complains to the nurse that her vision has become blurred since she started taking an
anticholinergic medication. The best response of the nurse would be:
a. “You need to schedule an appointment with your eye doctor to get a new prescription for your eyeglasses.”
b. “Blurred vision is a temporary side effect of your medication that usually resolves with 4 to 6 weeks.”
c. “You need to stop taking your antipsychotic medication and notify your doctor immediately.”
d. “Blurred vision is a permanent condition as a result of your medication.”
Answer: B
Rationale: Blurred vision is an anticholinergic symptom/side effect that usually resolves in a few weeks. If there
is no improvement with time, then the doctor should be notified. It is too early to schedule an appointment
(option A). The blurred vision is expected and usually resolves in a few weeks (option C). Permanent condition of
blurred vision is unusual (option D).
54. A male client is planning to be discharged from the hospital. It is your responsibility as the nurse to educate
this client regarding his medications. This client is taking an anticholinergic medication. A critical client teaching
point would include:
a. To report eye pain immediately to doctor.
b. To take this medication on an empty stomach.
c. To explain that the client may experience sudden changes in his bowel functioning in time.
d. That most over-the-counter medications are compatible with this medication.
Answer: A
Rationale: Eye pain may indicate undiagnosed narrow angle glaucoma, which needs immediate attention. This
condition is known as mydriasis. It is not necessary to take anticholinergic medication on an empty stomach
(option B). Constipation is a common side effect of anticholinergic medications (option C). Most over-the-counter
medications are not compatible with anticholinergic medications (option D).
55. Which of the following is considered to be a positive symptom associated with schizophrenia?
a. Alogia
b. Avolition
c. Social withdrawal
d. Loose associations
Answer: D
Rationale: Loose associations are considered to be a positive symptom associated with schizophrenia because
they indicate a distortion or excess of normal functioning. Alogia (option A), avolition (option B), and social
withdrawal (option C) are considered negative symptoms of schizophrenia. Negative symptoms indicate a loss or
lack of normal functioning. Negative symptoms develop over time and hinder the client’s ability to endure life
tasks.
SITUATION: Schizophrenia is a mental disorder that makes it difficult to tell the difference between real and
unreal experiences, to think logically, to have normal emotional responses, and to behave normally in social
situations.
56. A client is informed that his family refuses to allow him to return to the family's home because of recent
violent behavior. The client's expression remains blank; there is no apparent reaction to this statement. The
client then asks what time dinner is served. The client is exhibiting:
a. Blunted affect
b. Inappropriate affect
c. Mutism
d. Flat affect
Answer: D
Flat affect is defined as a total lack of emotion or expression. The client does not appear to display inappropriate
or incongruent affect. Blunted affect is defined as having a minimal emotional response to a person or event.
Mutism is defined as an inability or refusal to speak when able to do so.
Reference: Kneisl. Contemporary Psychiatric Mental Health Nursing 2nd edition
57. A client tells the nurse, "I refuse to take quetiapine (Seroquel) because it is manufactured by Al Qaeda. If I
take it, I'll die." This is an example of:
a. A negative symptom of schizophrenia called avolition.
c. A negative symptom of schizophrenia called alogia.
b. A characteristic of schizophrenia called ambivalence.
d. A positive symptom of schizophrenia called delusion.
Answer: D
The client's statement is an example of the positive symptom of schizophrenia called delusion, which is a
mistaken or false belief about the self or the environment. The client's statement is not an example of
ambivalence which is defined as concurrent conflicting emotions, thoughts, or actions toward a person, object, or
concept. It is also not an example of the tendency to use minimal words to speak called alogia, or of a lack of
motivation called avolition.
Reference: Kneisl. Contemporary Psychiatric Mental Health Nursing 2nd edition
58. Which of the following statements are accurate descriptions of schizoaffective disorder?
a. The prognosis for schizoaffective disorder is substantially worse than for schizophrenia.
b. Alterations in mood and thought process occur simultaneously in schizoaffective disorder.
c. A client with schizoaffective disorder usually has hallucinations and delusions only when experiencing a manic
or depressed state.
d. The mood component of schizoaffective disorder is depression.
Answer: B
Alterations in mood and thought process occurring simultaneously accurately describe schizoaffective disorder.
The prognosis for schizoaffective disorder is slightly better than for schizophrenia. Schizoaffective disorder is
associated with mania and depression. A client with schizoaffective disorder may have hallucinations and
delusions at any time despite one's mood.
Reference: Kneisl. Contemporary Psychiatric Mental Health Nursing 2nd edition
59. Which of the following behaviors is characteristic of a client with disorganized schizophrenia?
a. A client tells the nurse he is being "monitored" by the NBI.
b. A client sits in the corner rocking back and forth crying because "the voices are telling me I am a lousy goodfor-nothing."
c. A client tells the nurse, "All is well, but the well is dry, so why bother with clock and tock, mock, lock, jock."
d. A client comes to the nursing station and asks for something to "help calm my nerves."
ANSWER: C
This client is manifesting looseness of association and clanging, which is manifestation of disorganized thoughts
and speech. Option A: This client is verbalizing paranoid thoughts. Option B: This client is verbalizing auditory
hallucinations, which are a positive symptom of schizophrenia. Option D: This is an appropriate request.
Reference: Kneisl. Contemporary Psychiatric Mental Health Nursing 2nd edition
60. A client who is diagnosed with schizophrenia, paranoid type, tells the nurse, "I will take these antipsychotic
medications to help alleviate the voices. I will not take these antipsychotic medications because of the weight
gain." This client is exhibiting:
a. Magical thinking
b. Noncompliance
c. Body image disturbance
d. Decisional conflict
ANSWER: D
Decisional conflict, which may be due to biochemical changes in the brain, is correct. The client is having difficulty
deciding whether or not to take antipsychotic medication. The client is not exhibiting noncompliance, or refusal to
adhere to the treatment regimen. However, noncompliance may occur as a result of ambivalence and decisional
conflict. The client is not exhibiting body image disturbance though this is common in people with schizophrenia
in which clients may lose the sense of where their bodies leave off and where inanimate objects begin. The client
is not expressing magical thinking, which is characterized by the idea that events can occur because someone
wishes them to occur.
Reference: Kneisl. Contemporary Psychiatric Mental Health Nursing 2nd edition
61. Which one of the following contributing factors is considered to be the main causative factor in clients with
positive symptoms of schizophrenia with little or no evidence of negative symptoms?
a. Environmental agents
c. Highly emotive family members
b. Structural defects in the brain
d. Dysregulation of biochemical processes
ANSWER: D
Dysregulation of biochemical processes is considered to be the main causative factor in clients with positive
symptoms of schizophrenia with little or no evidence of negative symptoms. High levels of dopamine have been
related to hallucinations and delusions.
Reference: Antai-otong Psychiatric Nursing: Biologic and Behavioral concept. 2nd edition
62. The psychiatric mental health nurse is aware that hallucinations progress through stages including
comforting, condemning, threatening, and:
a. Reassuring
b. Controlling
c. Entertaining
d. Frightening
ANSWER: B
The stages progress through comforting, condemning, threatening, and controlling. Once the hallucinations have
reached the stage of controlling, the person is at the panic level and has no ability to control any behaviors or
actions. The hallucinations are in control, which presents a dangerous situation. It is during this stage that the
client is at risk for suicidal or homicidal behaviors.
Reference: Antai-otong Psychiatric Nursing: Biologic and Behavioral concept. 2nd edition
63. A client is receiving a traditional antipsychotic medication for his schizophrenia. The nurse would assess for
which of the following side effects:
a. Disturbing nightmares and night sweats
c. Hypoglycemia and parasympathetic disorders
b. Gastric reflux and restless leg syndrome
d. Orthostatic hypotension and autonomic disturbances
ANSWER: D
Common side effects of antipsychotic medication include orthostatic hypotension and autonomic disturbances.
Orthostatic hypotension occurs when the client changes positions too abruptly and is most common when the
client is moving from a sitting position to a standing position. Autonomic disturbances include dry mouth and
blurred vision. Hypoglycemia, gastric reflux, restless leg syndrome, and parasympathetic disorders are not typical
side effects of antipsychotic medications.
Reference: Antai-otong Psychiatric Nursing: Biologic and Behavioral concept. 2nd edition
64. Before Clozaril is administered to a client with schizophrenia, the nurse should:
a. Take the client’s temperature
c. Assure that blood work has been completed
b. Measure the client’s intake and output
d. Ask the client to sit quietly for at least 20 minutes
ANSWER: C
Baseline blood work should be obtained before the client is begun on Clozaril. This will provide a reference point
for future required lab work.
Reference: Antai-otong Psychiatric Nursing: Biologic and Behavioral concept. 2nd edition
65. Which is the priority of care in the client with catatonic schizophrenia?
a. Maintenance of nutritional status
c. Medicate for acting out behavior
b. Participation in all unit activities
d. Medicate for delusional thinking
ANSWER: A
Clients with catatonic schizophrenia frequently are unable to feed themselves. Therefore, the nurse must assess
the client’s nutritional status and provide assistance with meals as needed.
Reference: Antai-otong Psychiatric Nursing: Biologic and Behavioral concept. 2nd edition
66. The neuroleptic malignant syndrome was resolved and the client will resume taking the prescribed
antipsychotic medication. Which of the following statements, if made by the client, would indicate an
understanding of the resumption of antipsychotic medications?
a. “After three days I will resume my medication”
c. “I can restart my medication after 2 to 3 weeks”
b. “Immediately after the resolution of NMS’
d. “I can resume anytime I feel like taking the medications”
ANSWER: C
Antipsychotics should not be reinstituted for at least 2 weeks after complete resolution of NMS.
Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 221
67. Nurse Mike notices Leroy to be listening to someone who is not discernible. Without warning, he would shout
angrily and would then abruptly stop. Which nursing intervention is the most appropriate?
a. Approach Leroy and tap him to get his attention.
b. Encourage Leroy to go to his room to avoid distractions.
c. Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices.
d. Ask the client to describe what the voices are saying.
ANSWER: C
By acknowledging that the client hears voices, the nurse conveys acceptance of the client. By letting the client
know that the nurse doesn't hear the voices, the nurse avoids reinforcing the hallucination. The nurse shouldn't
touch the client with schizophrenia without advance warning. The hallucinating client may believe that the touch
is a threat or act of aggression and respond violently. Being alone in his room encourages the client to withdraw
and may promote more hallucinations. The nurse should provide an activity to distract the client. By asking the
client what the voices are saying, the nurse is reinforcing the hallucination. The nurse should focus on the client's
feelings, rather than the content of the hallucination.
Reference. Norman Keltner. Psychiatric Nursing. 5th edition. Page 357-358.
68. A client is admitted to the psychiatric unit with active psychosis. The physician diagnoses schizophrenia after
ruling out several other conditions. Schizophrenia is characterized by:
a. Loss of identity and self-esteem.
b. Multiple personalities and decreased self-esteem.
c. Persistent memory impairment and confusion.
d. Disturbances in affect, perception, and thought content and form.
ANSWER: D
The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, defines schizophrenia as a disturbance in
multiple psychological processes that affects thought content and form, perception, affect, sense of self, volition,
relationship to the external world, and psychomotor behavior. Loss of identity sometimes occurs but is only one
characteristic of the disorder. Multiple personalities typify multiple personality disorder, a dissociative personality
disorder. Mood disorders are commonly accompanied by increased or decreased self-esteem. Schizophrenia
doesn't cause a disturbance in sensorium, although the client may exhibit confusion, disorientation, and memory
impairment during the acute phase.
Reference: Videbeck, S.L. (2008) Psychiatric Mental Health Nursing 5th Edition.
69. A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief that one is:
a. Highly important or famous.
c. Connected to events unrelated to oneself.
b. Being persecuted.
d. Responsible for the evil in the world.
ANSWER: A
A delusion of grandeur is a false belief that one is highly important or famous. A delusion of persecution is a false
belief that one is being persecuted. A delusion of reference is a false belief that one is connected to events
unrelated to oneself or a belief that one is responsible for the evil in the world.
Reference: Videbeck, S.L. (2008) Psychiatric Mental Health Nursing 5th Edition.
70. A schizophrenic client is hearing a voice telling him that he must kill the nurse. Nurse Isabelle understands
that the client is exhibiting:
a. A delusion
b. Flight of ideas
c. A hallucination
d. Ideas of reference
ANSWER: C
A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client
experiences. A delusion is a false belief. Flight of ideas refers to a speech pattern in which the client skips from
one unrelated subject to another. Ideas of reference refers to the mistaken belief that someone or something
outside the client is controlling the client's ideas or behavior.
Reference: Videbeck, S.L. (2008) Psychiatric Mental Health Nursing 5th Edition.
71. Which information is most important for the nurse to include in a teaching plan for a schizophrenic client
taking clozapine (Clozaril)?
a. Monthly blood tests will be necessary.
c. Blood pressure must be monitored for hypertension.
b. Report a sore throat or fever to the physician immediately. d. Stop the medication when symptoms subside.
ANSWER: B
A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening
complication of clozapine therapy. Because of the risk of agranulocytosis, white blood cell (WBC) counts are
necessary weekly, not monthly. If the WBC count drops below 3,000/µl, the medication must be stopped.
Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness
from orthostatic hypotension. The medication should be continued, even when symptoms have been controlled. If
the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of
a physician.
Reference: Videbeck, S.L. (2008) Psychiatric Mental Health Nursing 5th Edition.
72. A client has been receiving chlorpromazine (Thorazine) for his psychosis. Which assessment findings should
alert Nurse Hannah that the client is experiencing pseudoparkinsonism?
a. Restlessness, difficulty sitting still, and pacing
b. Involuntary rolling of the eyes
c. Tremors, shuffling gait, and masklike face
d. Extremity and neck spasms, facial grimacing, and jerky movements
ANSWER: C
Pseudoparkinsonism may appear 1 to 5 days after starting an antipsychotic and may also include drooling,
rigidity, and "pill rolling." Akathisia may occur several weeks after starting antipsychotic therapy and consists of
restlessness, difficulty sitting still, and fidgeting. An occulogyric crisis is recognized by uncontrollable rolling back
of the eyes and, along with dystonia, should be considered an emergency. Dystonia may occur minutes to hours
after receiving an antipsychotic and may include extremity and neck spasms, jerky muscle movements, and facial
grimacing.
Reference: Videbeck, S.L. (2008) Psychiatric Mental Health Nursing 5th Edition.
73. Extrapyramidal symptoms are a serious neurologic side effect of antipsychotic drugs. Which drug is used to
control the extrapyramidal effects associated with antipsychotic agents?
a. Biperiden (Akineton)
b. Perphenazine (Trilafon) c. Doxepin (Sinequan)
d. Clorazepate (Tranxene)
ANSWER: A
Biperiden is an anticholinergic drug used to relieve drug-induced extrapyramidal adverse effects, such as muscle
weakness, involuntary muscle movement, pseudoparkinsonism, and tardive dyskinesia. Other anticholinergic
agents used to control extrapyramidal reactions include benztropine mesylate (Cogentin), trihexyphenidyl
(Artane), biperiden (Akineton), and diphenhydramine (Benadryl). Perphenazine is an antipsychotic agent;
doxepin, an antidepressant; and chlorazepate, an antianxiety agent. Because these medications have no
anticholinergic or neurotransmitter effects, they don't alleviate extrapyramidal reactions.
Reference: Videbeck, S.L. (2008) Psychiatric Mental Health Nursing 5th Edition.
74. Nurse Isabelle is caring for a client with schizophrenia who experiences auditory hallucinations. The client
appears to be listening and talking to someone who isn't there. He gestures, shouts angrily, and stops shouting in
mid-sentence. Which of the following nursing intervention is most appropriate?
a. Approach the client and gently touch him to get his attention
b. Encourage the client to go to his room where he'll experience fewer distractions
c. Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices
d. Ask the client to describe what the voices are saying.
ANSWER: C
By acknowledging that the client hears voices, the nurse conveys acceptance of the client. By letting the client
know that the nurse doesn't hear the voices, the nurse avoids reinforcing the hallucination. The nurse shouldn't
touch the client with schizophrenia without advance warning. The hallucinating client may believe that the touch
is a threat or act of aggression and respond violently. Being alone in his room encourages the client to withdraw
and may promote more hallucinations. The nurse should provide an activity to distract the client. By asking the
client what the voices are saying, the nurse is reinforcing the hallucination. The nurse should focus on the client's
feelings
rather than the content of the hallucination.
Reference: Videbeck, S.L. (2008) Psychiatric Mental Health Nursing 5th Edition.
75. Health teaching for a client taking an antipsychotic medication includes all but one:
a. The patient can eat sugar-free candy to relive mouth dryness
b. Thioridazine is contraindicated for clients with history of cardiac dysrhythmias
c. If the missed dose is more than 5 hours overdue, the client can still take the drug
d. Weekly WBC count throughout treatment is indicated for Clozapine therapy
ANSWER: C
If the client forgets a dose of antipsychotic medication, he or she can take the missed dose if it is only 3 or 4
hours late. If the dose is more than 4 hours overdue or the next dose is due, the client can omit the forgotten
dose. Option A: Correct intervention for anticholinergic side effects of antipsychotics. Option B: Droperidol,
Thioridazine, Mesoridazine can cause lengthening of QT interval, and is associated with life-threatening
dysrhythmias and sudden death. Option D: Antipsychotic medication may cause agranulocytosis. Weekly WBC
count throughout treatment and for 4 weeks after discontinuation of clozapine is necessary.
Reference: Videbeck, S.L. (2008) Psychiatric Mental Health Nursing 5th Edition.
76. A hospitalized client sees snakes on the walls of the hospital room and becomes anxious. This is an example
of which of the following?
a. Delirium
b. Delusion
c. Hallucination
d. Psychosis
ANSWER: B
Hallucinations involve seeing things that are not really there. Option A: Delirium is a change in consciousness
that occurs quickly. Option B: Delusions are false ideas that resist change. Option D: Psychosis is a mental
disorder in which contact with reality usually is impaired.
Reference: Videbeck, S.L. (2008) Psychiatric Mental Health Nursing 5th Edition.
SITUATION: Schizophrenia is characterized by a broad range of unusual behaviors that cause profound
disruption in the lives of people suffering from the condition, as well as in the lives of the people around them.
Schizophrenia strikes without regard to gender, race, social class or culture.
77. Nurse Izza is caring for a male client who experiences false sensory perceptions with no basis in reality. This
perception is known as:
a. Delusions
b. Perseveration
c. Neologisms
d. Hallucinations
ANSWER: D
Hallucinations are visual, auditory, gustatory, tactile or olfactory perceptions that have no basis in reality.
Delusion is fixed, false belief with no basis in reality.
Perseveration is unusual speech pattern which means persistent adherence to a single idea or topic and verbal
repetition of a sentence, phrase or word, even when other wants to change the topic.
Neologism is unusual speech pattern which patient invented words.
Reference: Videbeck, Sheila L. Psychiatric Mental Health Nursing, 2nd edition, Page 287-288.
78. A client with a history of schizophrenia has been admitted for suicidal ideation. The client states "Sinasabi sa
akin ng diyos na patayin ko na ang sarili ko” The nurse's best response would be:
a. “Nauunawaan ko na ng boses ng diyos ay tunay sa iyo, pero hindi ko sya naririnig. Sasamahan muna kita”
b. “Ang mga tinig ay bahagi ng iyong mga karamdaman; ito ay titigil kung iinumin mo ang gamot”
c. “Ang mga tinig ay parte lamang ng iyong imahinasyon; mag-isip ka ng iba at ito’y mawawala”
d. “Huwag ka ng mag-isip ng iba pa, mag-relax ka lang”
ANSWER: A
Option A acknowledge the patient’s feeling and at the same time it presents reality and most of all it ensures the
safety of the client. Staying with the client will help in safeguarding the patient for potential self harm.
Options BCD are non therapeutic.
Reference: Videbeck, Sheila L. Psychiatric Mental Health Nursing, 2nd edition, Page 106-124
79. A scheduled dose of haloperidol (Haldol) should be withheld from the client based on which assessment
finding?
a. Dizziness when standing
c. Urinary retention
b. Shuffling gait and hand tremors
d. Fever of 102° F
ANSWER: D
A fever (Option D) may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of
antipsychotics. The healthcare provider should be contacted before administering the next dose of Haldol.
(options A, B, and C) are all adverse effects of Haldol which can be managed
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 112
80. A client who's taking haloperidol (Haldol) develops a very high temperature, severe muscle rigidity,
hypertension, and changes in level of consciousness. Nurse Gigi suspects what complication of antipsychotic
therapy?
a. Extrapyramidal side effects
c. Neuroleptic malignant syndrome (NMS)
b. Agranulocytosis
d. Anticholinergic effects
ANSWER: C
A rare but potentially fatal condition of antipsychotic medication is called NMS. In NMS, severe muscle rigidity
develops with elevated temperature and a rapidly accelerating cascade of symptoms (occurring during the next
48 to 72 hours), which can include two or more of the following: hypertension, tachycardia, tachypnea,
diaphoresis, incontinence, changes in LOC ranging from confusion to coma.. Agranulocytosis is a blood disorder.
Anticholinergic effects include blurred vision, drowsiness, and dry mouth. Symptoms of extrapyramidal effects
include tremors, restlessness, muscle spasms, and pseudoparkinsonism.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 305
81. Based on non-compliance with the medication regimen, an adult client with a medical diagnosis of substance
abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine
decanoate (Prolixin Decanoate). The client and family should be taught which of the following important points
about this change in medication regimen?
a. Signs and symptoms of extrapyramidal effects (EPS).
b. Information about substance abuse and schizophrenia.
c. The effects of alcohol and drug interaction.
d. The availability of support groups for those with dual diagnoses.
Answer: C
Alcohol enhances the EPS side effects of Prolixin. The half-life of Prolixin PO is 8 hours, whereas the half-life of
the Prolixin Decanoate IM is 2 to 4 weeks. That means the side effects of drinking alcohol are far more severe
when the client drinks alcohol after taking the long-acting Prolixin Decanoate IM. Options A, B, and D provide
valuable information and should be included in the client/family teaching, but they do not have the priority of
option C
Reference: Amy Karch. Focus on Nursing Pharmacology. 3rd edition. Page 328
82. Incomprehensible language is characteristic of persons with schizophrenia. A client is telling you about his
hallucinations of Indians on the wind calling out to him “ipeechee.” You offer the client a drink of water, and the
client says, “Emanah.” You wonder about these words, which seem created by the client. If in your assessment
you discover that the client makes up these words, they are good examples of which of the following?
a. Incoherence
b. Neologisms
c. Tangentiality
d. Word salad
ANSWER: B
The client’s use of the words ipeechee and Emanah are examples of neologisms. Neologistic words are words
invented by the individual with schizophrenia.
Reference: Noreen Cavan Frisch. Psychiatric Mental Health Nursing. 4th ed.
83. A client was admitted to the unit with a diagnosis of schizophrenia. In a report, you learn that this client was
admitted after the client smashed the television in a group home. This client is said to have been isolated in his
room and rocking in the corner. This client refuses to go into the community room where the television set is
located, because he believes it can see him and record his thoughts. This client also believes the news
commentators are always talking about him and his family. Which type of delusions does this client have?
a. Grandiose
b. Persecutory
c. Referential
d. Telecommunication
ANSWER: C
The belief that the television set can see him and record his thoughts is an example of a referential delusion.
Persons with referential delusions believe that common events such as passages in songs, patterns of clouds in
the sky, or comments of others on the radio or television refer specifically to them.
Reference: Noreen Cavan Frisch. Psychiatric Mental Health Nursing. 4th ed.
84. You are assigned to a client with schizophrenia. You find that this client has lessened reactivity to the
environment, rigid posture, resistance to being moved, and even bizarre posturing. Which of the following words
is used in psychiatric nursing and the psychiatric field to describe these behaviors of your client?
a. Catatonia
c. Neuroleptic malignant syndrome
b. Posture fixation
d. Postsynaptic paralytic condition
ANSWER: A
Catatonia is a marked decrease in reactivity to the environment, sometimes reaching an extreme degree of
complete unawareness. The catatonic individual maintains a rigid posture and resists efforts to be moved.
Catatonia is among the most striking psychotic manifestations.
Reference: Noreen Cavan Frisch. Psychiatric Mental Health Nursing. 4th ed.
85. One of the primary goals in providing rehabilitation services to clients with schizophrenia is to:
a. Obtain good paying employment for them
c. Help them problem solve in everyday social challenges
b. Eliminate the presence of negative symptoms
d. Reduce psychotic relapse rates significantly to save money
ANSWER: C
A primary goal in providing rehabilitation services to clients with schizophrenia is to help the clients problem solve
in everyday social challenges. Because of the negative symptoms of schizophrenia, social functioning is often
problematic. Rehabilitation provides training in social functioning that can potentially increase knowledge and
skills levels of clients. It may also reduce rates of psychotic relapse as a result of the reduced social isolation.
Reference: Noreen Cavan Frisch. Psychiatric Mental Health Nursing. 4th ed.
86. Another client, with paranoid schizophrenia, has persecutory delusions and auditory hallucinations and is
extremely agitated. He has been given a PRN dose of Thorazine IM. Which of the following would indicate to the
nurse that the medication is having the desired effect?
a. Complains of dry mouth
c. Stops pacing and sits with the nurse
b. State he feels restless in his body
d. Exhibits increased activity and speech
ANSWER: C
Chlorpromazine (Thorazine) is a conventional antipsychotic drug that is used in treating the signs and symptoms
of psychosis, such as delusions and hallucinations seen in schizophrenic clients. If the client stopped pacing and
sits with the nurse, it means the medication is working since it acts by blocking dopamine, which is an excitatory
neurotransmitter.
Reference: Videbeck, Sheila L. Psychiatric Mental Health Nursing, 2nd edition, Page 23, 29.
87. After 3 days of taking haloperidol, the client shows an inability to sit still, is restless and fidgety, and paces
around the unit. Of the following extrapyramidal adverse reactions, the client is showing signs of:
a. Dystonia
b. Akathisia
c. Parkinsonism
d. Tardive dyskinesia
ANSWER: B
Akathisia is characterized by restlessness movement, pacing, inability to remain still, and the client’s report of
inner restlessness. It usually develops when the antipsychotic is started or when the dose is increased.
Dystonia from antipsychotic medication appear early in the course of treatment and are characterized by spasms
in discrete muscle groups such as oculogyric muscles and neck muscles like torticollis.
Pseudo Parkinsonism includes a shuffling gait, mask like facies, muscle stiffness or cogwheeling rigidity, drooling
and akinesia. It appears in the first days of the treatment.
Tardive dyskinesia is a late appearing side effect of antipsychotic medications, is characterized by abnormal,
involuntary movements such as lip smacking, tongue protrusion, chewing, blinking, grimacing, and choreiform
movements of the feet and limbs.
Reference: Videbeck, Sheila L. Psychiatric Mental Health Nursing, 2nd edition, Page 283-284
88. Which of the following problems is most often associated with taking clozapine?
a. Constipation
b. Retrolental fibroplasia
c. Agranulocytosis
d. Proliferation of macrophages
ANSWER: C
Agranulocytosis is a problem associated with taking clozapine. Some clients experience a reduction in their white
blood cell count requiring that the medication be discontinued.
Reference: Noreen Cavan Frisch. Psychiatric Mental Health Nursing. 4th ed.
89. You are working with a client who is taking a neuroleptic medication that has recently been changed and
increased. You notice that the client has a high fever (104 degrees Fahrenheit), is confused, and has extreme
muscle rigidity. You would do which of the following?
a. Suspect neuroleptic malignant syndrome, hold the neuroleptic medication, and call the health care provider.
b. Suspect that the client has an infectious process, and call the health care provider, expecting an order for an
antibiotic.
c. Call an ambulance immediately, notify the health care provider, and prepare for seizure control and
cardiopulmonary resuscitation (CPR).
d. Give the neuroleptic on time as ordered, call the health care provider to report the symptoms, and see if
additional medication is needed.
ANSWER: A
The high fever, confusion, and muscle rigiditt is an indication that the client is experiencing neuroleptic malignant
syndrome. The nurse should hold the medication and call the health care provider immediately. Neuroleptic
malignant syndrome is the rarest side effect. If left untreated, it may rapidly lead to death.
Reference: Noreen Cavan Frisch. Psychiatric Mental Health Nursing. 4th ed.
90. The nurse was visiting in the home of a family who cares for an 18-year-old son with chronic schizophrenia.
The parents remarked, “We never go anywhere alone, and we are thinking about taking a weekend trip. What do
you think?” Which response would be most helpful to them?
a. “It has to be tough, but you sure do a good job with your son.”
b. “Maybe you should leave for a few hours first to see if your son objects.”
c. “It will be difficult to find someone willing to stay in your home.”
d. “You do need to have some time away together.”
ANSWER: D
The most helpful response by the nurse is to acknowledge that the parents need time for themselves. Caring for
a person with a chronic health condition provides added stress for the caregiver. Respite care is a possible
solution. Respite care can come in many forms such as temporary placement for the son while the parents take a
vacation. Another option would be to hire another caregiver to be with the son while the family takes a vacation.
Reference: Noreen Cavan Frisch. Psychiatric Mental Health Nursing. 4th ed.
91. A young adult who has long-term schizophrenia was admitted to the hospital from a group home after
threatening the neighbors. The client’s medication was changed, and after stabilization, this client was returned
to the community. Which individual is most likely to oversee this young adult client’s treatment plan?
a. The hospital physician
b. A home health nurse
c. The case manager
d. A psychiatric staff nurse
ANSWER: C
The case manager would be most likely to oversee the client’s treatment plan. Case managers, a position often
held by nurses, help persons who are seriously mentally ill to build skills and access supports so they can function
as independently as possible.
Reference: Noreen Cavan Frisch. Psychiatric Mental Health Nursing. 4th ed.
92. A client with chronic paranoid schizophrenia is scheduled to be discharged from the inpatient psychiatric unit
in two days. The nurse is working with the client's family to develop a plan for managing psychotic symptoms and
emergency behaviors after discharge. Which of the following nursing diagnoses is most appropriate?
a. Self-care deficit: bathing/hygiene related to irrational thought processes
b. Knowledge deficit: symptom management related to inadequate understanding of disease processes
c. Noncompliance: medication regimen related to paranoid ideation
d. Risk for violence directed toward others related to delusional and persecutory thought process
ANSWER: B
Nurses should partner with the client and family to determine a mutually agreeable plan for a safe, secure, and
supportive living arrangement following discharge. This includes a plan for managing symptoms by reducing
schedule demands and/or contacting the mental health team or case manager for assistance. Family members
need guidance in how to recognize relapse and exacerbation of symptoms as well as what to do in an emergency
situation. Noncompliance with medications, self-care deficits, and potential for violent behaviors are nursing
diagnoses more appropriate for clients in the inpatient setting but do not help the family prepare for challenges
after discharge.
Reference: Noreen Cavan Frisch. Psychiatric Mental Health Nursing. 4th ed.
93. The definition of nihilistic delusions is:
a. a false belief about the functioning of the body.
b. belief that the body is deformed or defective in a specific way.
c. false ideas about the self, others, or the world.
d. the inability to carry out motor activities.
ANSWER: C
Nihilistic delusions are false ideas about the self, others, or the world. Somatic delusions involve a false belief
about the functioning of the body. Body dysmorphic disorder is characterized by a belief that the body is
deformed or defective in a specific way. Apraxia is the inability to carry out motor activities.
94. A client is unable to get out of bed and get dressed unless the nurse prompts every step. This is an example
of which behavior?
a. Word salad
b. Tangential
c. Perseveration
d. Avolition
ANSWER: D
Avolition refers to impairment in the ability to initiate goal-directed activity. Word salad is a behavior in which a
group of words are put together in a random fashion without logical connection. A person exhibiting tangential
behavior never gets to the point of the communication. In perseveration, a person repeats the same word or idea
in response to different questions.
95. A patient is receiving a neuroleptic medication. The nurse should assess the patient for an acute dystonic
reaction which includes:
a. Ataxic gait
b. Oculogyric crisis
c. Cogwheeling
d. Lip smacking
ANSWER: B
Dystonic reactions to antipsychotic medication appear early in the course of the treatment and are characterized
by spasms in discrete muscle groups such as the neck muscles (torticollis) or eye muscles (Oculogyric crisis).
This may also me accompanied by dysphagia and laryngeal/pharyngeal spasms. Options a and c are symptoms
of pseudoparkinsonism while option d is a symptom of tardive dyskinesia.
96. A patient being treated for schizophrenia has his medication changed from thioridazine (Mellaril) to clozapine
(Clozaril), the nurse should be more vigilant in assessing the patient for potentially fatal side effect manifested
by:
a. Constipation
b. Dry mouth
c. Orthostatic hypotension
d. Fever
ANSWER: D
Options a, b and c are side-effects of this medication. Clozapine has the potentially fatal side-effect of
agranulocytosis which is manifested by fever, malaise, ulcerative sore throat, and leucopenia. Blood samples are
taken weekly to monitor the WBC count of the client.
97. A schizophrenic patient tells the nurse, “You are wearing a pretty red dress, tomatoes are red, vegetables
make you healthy, I am not healthy”. A nurse should recognize that the statement made by the client is an
example of:
a. Confabulation
b. Echolalia
c. Looseness of association
d. Neologisms
ANSWER: C
This is an example of loose association. In a loose association, there is a disorganized thinking that jumps from
one idea to another with little or no evident relation between the thoughts. Echolalia is the client’s imitation or
repetition of what the nurse’s say. Neologism is the use of invented words that have meaning only for the client.
Confabulation is making up answers to fill-in memory gaps.
98. A newly admitted patient can't take care of his personal needs, shows insensitivity to painful stimuli, and
exhibits negativism, rigidity, and posturing. The nurse would suspect which diagnosis?
a. Paranoid Schizophrenia
c. Undifferentiated Schizophrenia
b. Residual Schizophrenia
d. Catatonic Schizophrenia
ANSWER: D
Catatonic schizophrenia is characterized by the inability to take care of personal needs, diminished sensitivity to
painful stimuli, negativism, rigidity, and posturing. Paranoid schizophrenia is characterized by preoccupation with
one or more delusions or frequent auditory hallucinations. Residual schizophrenia is characterized by a history of
at least one schizophrenic episode and the waning or absence of delusions , hallucinations, disorganized speech,
and grossly disorganized or catatonic behavior. Undifferentiated schizophrenia is characterized by delusions,
prominent hallucinations, disorganized speech, grossly disorganized behavior, and negative symptioms.
Source: Straight A's in Psychiatric and Mental Health Nursing by LWW copyright 2006. p.115
99. A client state: “The nofas are coming.” In response to this neologism, it would be best for the nurse to:
a. Divert the client’s attention to an aspect of reality.
b. State that what the client is saying has not been understood and then divert attention to something that is
reality- based.
c. Acknowledge that the word has some special meaning to the client.
d. Try to interpret what the client means.
ANSWER: C
It is important to acknowledge a statement, even if it is not understood.
A – It is not a direct response.
B – It leaves out the importance of the meaning of the neologism to the client.
D - Less valid and important than acknowledgment of the meaning to the client.
Source: Tutor-Davis’s NCLEX-RN Success, 2nd edition
100. The client is laughing and telling a number of jokes to a group of clients. Suddenly, the client is in tears and
talks about a death in the family. A moment later, the client is laughing and joking again. The nurse interprets
this behavior as indicative of which of the following?
a. Flat affect
b. Blunted affect
c. Labile affect
d. Normal affect
ANSWER: C
The client is exhibiting a labile affect or an affect that quickly changes (e.g., from happy to sad). A flat affect
refers to an absence of facial expression or an expression that does not change even though the topic of what the
client is verbalizing changes. A blunted affect is an incomplete expression. Normal affect is one that changes
appropriately with the topic of conversation.
Source: Lippincott’s Review for NCLEX-RN Examination, by Diana Billings, 8th edition, page 563
MENTAL HEALTH AND PSYCHIATRIC NURSING
SUBSTANCE RELATED DISORDERS, VIOLENCE AND LEGAL ASPECTS OF PSYCHIATRIC NURSING
SITUATION: John Jun, a 40 year old father of two, voluntarily admits himself to the substance abuse unit. He
admits drinking 10 bottles or more of beer each day and occasionally uses cocaine. His job and marriage is in
jeopardy.
1. John Jun revealed that he experienced a marked increase in his alcohol intake to get drunk and achieve the
alcohol’s desired effect. John Jun’s statement would be indicative of which of the following?
a. Withdrawal
b. Tolerance
c. Intoxication
d. Psychological dependence
ANSWER: B
Tolerance is the need for greatly increased amounts of a substance to obtain the desired effect.
Option A: is the behavioral, physiologic, and cognitive symptoms that occur when blood or tissue concentrations
of a substance abruptly decline.
Option C: Intoxication is the use of a substance that results in maldaptive behavior. Option D: User's reliance on
the drug in order to function or have a feeling of well being. That is, the individual is said to have a psychological
reliance on the drug.
Reference: Lippincott’s Mental Health and Psychiatric Nursing.4th edition. Page 141
2. Later that day, John Jun begins to show signs of alcohol withdrawal. Which of the following medications must
be given to a client for safe alcohol withdrawal?
a. Librium
b. Clonidine
c. Methadone
d. Antabuse
ANSWER: A
Safe withdrawal is accomplished with the administration of benzodiazepines such as lorazepam (ativan),
chlordiazepoxide (Librium) or diazepam (valium) to suppress the withdrawal symptoms.
Option B: Clonidine stimulates alpha adrenergic receptor in the CNS, which reduces norepinephrine rebound
when opioid is stopped, suppresses opiate withdrawal.
Option C: for Opioid withdrawal,
Option D: Anatbuse is used to cause an aversion to alcohol. This drug interferes with the breakdown of alcohol,
causing an accumulation of acetaldehyde, a by-product of alcohol, in the body. Antabuse produces an unpleasant
reaction when taken with alcohol, including palpitations, vomiting, perspiration, dyspnea and thirst.
Reference: Videbeck. Psychiatric Mental Health Nursing. Page 388
3. A period of 72 hours had passed and John Jun develops increasing tremors, irritability, hypertension and fever.
The nurse should be alert for impending:
a. Delirium tremens
b. Korsakoff’s syndrome
c. Esophageal varices
d. Wernicke’s encephalopathy
ANSWER: A
Alcohol withdrawal show signs of anxiety, uncontrollable fear, tremor, irritability, agitation, insomnia, and
incontinence. They are talkative and preoccupied and experience visual, tactile, olfactory, and auditory
hallucinations that often are terrifying. Autonomic overactivity occurs and is evidenced by tachycardia, dilated
pupils, and profuse perspiration. Usually, all vital signs are elevated in the alcoholic toxic state. Elevated
temperature in excess of 37.3OC and pulse in excess of 100 beats per minute indicate impending Delirium
Tremens.
Option B: Korsakoff ’s syndrome: personality disorder characterized by psychosis, disorientation, delirium,
insomnia, and hallucinations.
Option C: Esophageal varices are dilated, tortuous veins usually found in the submucosa of the lower esophagus,
but they may develop higher in the esophagus or extend into the stomach. This condition nearly always is caused
by portal hypertension, which in turn is due to obstruction of the portal venous circulation within the damaged
liver. Option D: Wernicke’s encephalopathy, an inflammatory hemorhhagic, degenerative condition of the brain
caused by a thiamine deficiency. Clinical symptoms include double vision, involuntary and rapid eye movement,
lack of muscular coordination and decreased mental function, which may be mild or severe.
Reference: Lippincott’s Mental Health and Psychiatric Nursing.4th edition. Page 141. Brunner and Suddhart.
Medical Surgical Nursing. 10th edition 2170. Louise Shives. Psychiatric Mental Health Nursing. 7th edition. Page
437
4. Which of the following nursing interventions is a priority care for a client experiencing alcohol withdrawal?
a. Teach techniques to reduce anxiety
c. Administer benzodiazepine
b. Provide low fat diet
d. Encourage fluid intake
ANSWER: C
Because alcohol is a CNS depressant, withdrawal will cause the client’s central nervous system to be activated.
Administering Benzodiazepine takes priority when caring for client experiencing alcohol withdrawal. It will lower
BP and pulse, decrease anxiety and assist in preventing seizures and death. Encouraging fluids, providing three
well balanced meals and teaching techniques to reduce anxiety are all appropriate interventions but not a
priority.
Reference: Videbeck. Psychiatric Mental Health Nursing. Page 381
5. Which of the following orders should the nurse question when planning the nursing care for a client going into
alcohol withdrawal?
a. Eliminate coffee from diet
c. NPO
b. Assess vital signs every 2 to 4 hours
d. Teach relaxation technique
ANSWER: C
Fluids should be encouraged for clients experiencing alcohol withdrawal because they often experience
dehydration. Fluids would never be withheld. Assessing vital signs, teaching how to relax, and avoiding caffeine in
the diet are all appropriate nursing interventions for a client in alcohol withdrawal.
Reference: Videbeck. Psychiatric Mental Health Nursing. Page 388-395
6. The following are appropriate interventions for John Jun except:
a. Keeping the room dark to prevent overstimulation
b. Providing the patient in a calm, nonstressful environment and observed closely
c. Someone is designated to stay with the patient as much as possible.
d. Explain any visual misrepresentation to the client
ANSWER: A
The patient is placed in a calm, nonstressful environment (usually a private room) and observed closely. The
room remains lighted to minimize the potential for illusions and hallucinations. Homicidal or suicidal responses
may result from hallucinations. Closet and bathroom doors are closed to eliminate shadows. Someone is
designated to stay with the patient as much as possible. The presence of another person has a reassuring and
calming effect which helps the patient maintain contact with reality. Any visual misrepresentations (illusions) are
explained, to orient the patient to reality
Reference: Brunner and Suddhart. Medical Surgical Nursing. 10th edition. Page 2170-2175
7. The most effective treatment of alcoholism is accomplished by which of the following?
a. Individual or group therapy
c. Active membership in Alcoholics Anonymous (AA)
b. Admission to an alcoholic unit in hospital
d. Administration of disulfiram
ANSWER: D
Aversion therapy, one way of reversing the individual’s desire to seek and use an illicit substance, consists of
giving drug such as disulfiram (antabuse). This drug interferes with the breakdown of alcohol, causing an
accumulation of acetyldehyde, a by-product of alcohol in the body. The person who takes disulfiram and drinks
alcohol experiences severe nausea and vomiting, hypotension, headaches, rapid pulse and respirations, flushed
face, and bloodshot eyes.
Reference: Louise Shives. Psychiatric Mental Health Nursing. 7th edition. Page 452-453
SITUATION: Substance abuse, also known as drug abuse, maladaptive pattern of use of a substance that is not
considered dependent
8. The nurse understands that the essential difference between substance abuse and substance dependence is
that substance dependence:
a. Includes characteristics of tolerance and withdrawal.
b. Includes characteristics of adverse consequences and repeated use.
c. Produces less severe symptoms than that of abuse.
d. Requires long-term treatment in a hospital-based program.
ANSWER: A
Tolerance (the need to increase the amount of a substance to obtain desired effect) and withdrawal (symptoms
occurring when a substance is decreased or stopped) are the essential criteria in establishing substance
dependence. Both abuse and dependence produce adverse consequences and are characterized by repeated use.
Dependence would cause symptoms that are more severe, Option D is not necessarily true; after the initial
detoxification period, community-based treatment may be appropriate.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
9. The sister of a client with a substance-related disorder tells the nurse that she calls out sick for the client
occasionally when he has too much to drink and cannot work. This behavior can be described as:
a. Caretaking
b. Codependent
c. Helpful
d. Supportive
ANSWER: B
Enabling behaviors that inadvertently promote continued use of a substance by the person abusing substances is
known as codependency. The sister's behavior is not an example of caretaking or support. She is taking
responsibility for the client's behavior and allowing him to avoid the consequences of his abuse problem. The
behavior is unhelpful and unsupportive.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
10. When a client abuses a CNS depressant, withdrawal symptoms will be caused by which of the following?
a. Acetylcholine excess
b. Dopamine depletion
c. Serotonin inhibition
d. Norepinephrine rebound
ANSWER: D
CNS depressants, when abused, cause depletion of stimulating neurotransmitters. When the CNS depressant is
stopped, the result is a rebound of excitatory or stimulating neurotransmitters, such as norepinephrine.
Acetylcholine, dopamine, and serotonin are not significant factors in the symptoms of withdrawal from CNS
depressant.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
11. The general classification of drugs belonging to the opioid category is analgesic and:
a. Depressant
b. Hallucinogenic
c. Stimulant
d. Tranquilizing
ASNWER: A
Opiates are both analgesics and CNS depressants because they decrease the effect of neurotransmitters that are
excitatory or stimulating. Hallucinogenic and stimulant are categories that do not apply to opiates. Although an
opiate can provide a tranquilizing effect, the general category would be that of a depressant.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
12. The community nurse practicing primary prevention of alcohol abuse would target which groups for
educational efforts?
a. Adolescents in their late teens and young adults in their early twenties
b. Elderly men who live in retirement communities
c. Women working in careers outside the home
d. Women working in the home
ANSWER: A
High-risk groups for alcohol abuse include individuals between ages 18 and 25 and the unemployed. There is no
evidence that elderly men in retirement communities have increased rates of alcohol abuse. Men have a 2 to 3
times increased risk than women of abusing alcohol.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
13. A staff nurse has observed a coworker arriving to work drunk at least three times in the past month. Which
action by the nurse would best ensure client safety and obtain necessary assistance for the coworker?
a. Ignore the coworker's behavior, and frequently assess the clients assigned to the coworker.
b. Make general statements about safety issues at the next staff meeting.
c. Report the coworker's behavior to the appropriate supervisor.
d. Warn the coworker that this practice is unsafe.
ANSWER: C
The nurse is obligated by ethical considerations of client safety as well as by nurse practice acts in many states,
to report substance abuse in health care workers. Most health care facilities have an employee assistance
program to help workers with substance abuse problems. Ignoring the coworker's behavior would be a form of
enabling behavior (codependency) on the staff nurse's part. Making general statements about safety in a staff
meeting avoids dealing with the problem. Warning the coworker is inadequate; it does not ensure client safety or
help him receive necessary help.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
14. A client being treated in a chemical dependency unit tells the nurse that he only uses drugs when under
stress and therefore does not have a substance problem. Which defense mechanism is the client using?
a. Compensation
b. Denial
c. Suppression
d. Undoing
ANSWER: B
Individuals who have substance problems often use denial. Compensation, suppression, and undoing are
incorrect and do not fit the situation described.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
15. Nurse Mian is teaching a community group about substance abuse. She explains that a genetic component
has been implicated with which of the following commonly abused substances?
a. Alcohol
b. Barbiturates
c. Heroin
d. Marijuana
ANSWER: A
Several chromosomes (I, 3, and 7) have been implicated in increased vulnerability to alcohol abuse. Statistics
have shown that risk for alcohol abuse in first-degree relatives of alcohol abusers is as high as 4D% to 60%. Most
of the genetic research has been done related to alcohol. Definitive data regarding genetic transmission is not
available at this time for barbiturates, heroin and marijuana.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
16. The nurse recommends that the family of a client with a substance-related disorder attend a support group.
The purpose of these groups is to help family members understand the problem and to:
a. Change the problem behaviors of the abuser
b. Learn how to assist the abuser in getting help
c. Maintain focus on changing their own behaviors
d. Prevent substance problems in vulnerable family members.
ANSWER:
Family support groups emphasize the importance of changing one's own behavior rather than trying to change
the behavior of the individual with a substance abuse problem. Trying to change the abuser's behavior or learning
ways to find help for the abuser would be viewed as codependent behaviors. and thus would not be advocated by
family support groups. Learning about substance abuse may help a vulnerable family member to avoid this
problem; however, that is not the purpose of these groups.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
17. The nurse is assessing a client who is a chronic alcohol abuser. Which problems are related to thiamin
deficiency?
a. Cardiovascular symptoms, such as decreased hemoglobin and hematocrit levels
b. CNS symptoms, such as ataxia and peripheral neuropathy
c. Gastrointestinal symptoms, such as nausea and vomiting
d. Respiratory symptoms, such as cough and sore throat
ANSWER: B
Wernicke's encephalopathy is a CNS disorder caused by acute thiamin deficiency in people who abuse alcohol.
Other symptoms besides ataxia and peripheral neuropathy; are acute confusion or delirium. Cardiovascular and
gastrointestinal symptoms are associated with alcohol abuse; they are not caused by thiamin deficiency.
Respiratory problems are not usually directly related to alcohol.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
18. When assessing a client who abuses barbiturates and benzodiazepine, the nurse would observe for evidence
of which withdrawal symptoms?
a. Anxiety, tremors, and tachycardia
c. Muscle aches, cramps, and lacrimation
b. Respiratory depression, stupor, and bradycardia
d. Paranoia, depression, and agitation
ANSWER: A
Barbiturates and benzodiazepine are CNS depressants; therefore, withdrawal symptoms are related to CNS
stimulation caused by the rebounding of neurotransmitters (norepinephrine). Symptoms include increased
anxiety, tremors, and vital sign changes (such as tachycardia and hypertension). Respiratory depression, stupor,
and bradycardia are typically associated with an overdose-not withdrawal-of barbiturates or benzodiazepine.
Muscle aches. cramps, and lacrimation are most commonly associated with withdrawal from opiates. Paranoia,
depression and agitation are usually associated with withdrawal from CNS stimulants, such as amphetamines or
cocaine.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
19. When teaching an adolescent health class about the dangers of inhalant abuse, the nurse warns about the
possibility of:
a. Contracting an infectious disease, such as hepatitis or AIDS
b. Recurrent flashback events
c. Psychological dependence after initial use
d. Sudden death from cardiac or respiratory depression
ANSWER: D
Inhalants are CNS depressants; if taken in an excess amount they can cause cardiac and respiratory depression.
It is impossible to control the inhalant dosage; therefore, death can occur. Contracting an infectious disease,
recurrent flashback events, and psychological dependence after initial use are not associated with inhalant abuse.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
20. Which medication is commonly used in treatment programs for heroin abusers to produce a non euphoric
state and to replace heroin use?
a. Diazepam
b. Carbamazepine
c. Clonidine
d. Methadone
ANSWER: D
Methadone maintenance programs are used to provide a heroin-dependent individual with a medically controlled
dose of methadone to produce a non-euphoric state that will prevent withdrawal symptoms. This method of
treatment is advocated to help heroin abusers avoid criminal activities associated with obtaining heroin; it also
prevents diseases associated with LV use of heroin. Diazepam and carbamazepine may be used for withdrawal
from alcohol, barbiturates, and benzodiazepines. Clonidine can be used in acute withdrawal from heroin to avoid
norepinephrine rebound when opiates are stopped.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
21. The nurse administers bromocriptine (Parlodel) to a client undergoing detoxification for amphetamine abuse.
The rationale for this medication is to:
a. Aid in GABA inhibition
c. Restore depleted dopamine levels
b. Prevent norepinephrine excess
d. Treat psychotic symptoms
ANSWER:
Amphetamine abuse depletes the neurotransmitter dopamine. When withdrawing from amphetamines, dopamine
depletion causes depression, insomnia and intense craving for the drug. Bromocriptine (ParlodeJ) is a dopamine
agonist that will help restore this neurotransmitter GABA inhibition prevention of norepinephrine excess and
treatment of psychotic symptoms are incorrect rationales for the use of this medication.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
22. The nurse is teaching a client about disulfiram (Antabuse), which the client is taking to deter his use of
alcohol. She explains that using alcohol when taking this medication can result in:
a. Abdominal cramps and diarrhea.
c. Flushing, vomiting, and dizziness.
b. Drowsiness and decreased respiration.
d. Increased pulse and blood pressure.
ANSWER: C
Disulfiram (Antabuse) prevents complete alcohol metabolism in the body. Therefore, when alcohol is consumed,
the client has a hypersensitivity reaction. Flushing, vomiting, and dizziness are associated with the incomplete
breakdown of alcohol metabolites. Abdominal cramps, diarrhea, drowsiness, decreased respiration, and increased
pulse and blood pressure are not associated with the use of disulfiram along with alcohol.
Reference: Lippincott’s Mental Health and Psychiatric Nursing 4th edition
SITUATION: A 26-year-old patient has been admitted to the emergency department. He has a runny nose,
stomach cramps, dilated pupils, muscle spasms, chills despite the warm weather, elevated heart rate and blood
pressure, and is running a slight temperature. Aside from these symptoms, this man is fairly in good physical
shape. He has no other adverse medical and psychological problems.
23. Based on the clinical manifestations presented, he is experiencing which of the following substance abuse
related disorders?
a. Opioid intoxication
b. Opioid withdrawal
c. Anxiolytic withdrawal
d. Cannabis Intoxication
ANSWER: B
His signs and symptoms all indicate opiate withdrawal. He has a runny nose, stomach cramps, dilated pupils,
muscle spasms, chills, despite the warm weather, elevated heart rate and blood pressure, and is running a slight
temperature.
Option A: Opioid intoxication include symptoms like psychomotor retardation or agitation, constricted pupils,
drowsiness slurred speech and impaired attention and memory.
Option C: Anxiolytic withdrawal is characterized by autonomic hyperactivity, hand tremor, insomnia, anxiety,
nausea, psychomotor agitation.
Option D: Cannabis intoxication: impaired motor coordination, inappropriate laughter, impaired judgment and
short term memory, and distortions in time and perception, increased appetite.
Reference: Videbeck. Psychiatric Mental Health Nursing. Page 383-385
24. Which of the following drugs would be used to counteract the effects of opioid overdose?
a. Ritalin
b. Methadone
c. Dexedrine
d. Naloxone
ANSWER: D
Administration of naloxone, an opioid antagonist, is the treatment of choice for opioid overdose. It reverses all
signs of opioid toxicity. Naloxone is given every few hours until the opioid level drops to nontoxic; this process
may take days. Option A and C: Drug for ADHD, Option B: opioid withdrawal, used as a replacement for opioid.
Reference: Videbeck. Psychiatric Mental Health Nursing. Page 384
25. Which of the following should the nurse include in the plan of care for a client experiencing morphine sulfate
withdrawal?
a. Provide a cool room
c. Administer clonidine (Catapres)
b. Administer diazepam (valium)
d. Restrict fluids
ANSWER: C
Clopnidine (Catapres) blocks opioid receptor site more effectively than a CNS depressant (Valium) in the
treatment of morphine sulfate withdrawal. Most likely the client would complain of being chilled and require
multiple blankets or a warm whirlpool. Fluids are encouraged and not restricted.
Reference: Videbeck. Psychiatric Mental Health Nursing. Page 389
SITUATION: Substance abuse refers to the harmful or hazardous use of psychoactive substances, including
alcohol and illicit drugs. Psychoactive substance use can lead to dependence syndrome - a cluster of behavioural,
cognitive, and physiological phenomena that develop after repeated substance use and that typically include a
strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful
consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance,
and sometimes a physical withdrawal state.
26. A continuous or intermittent craving for a substance to avoid a dysphoric or unpleasant mood state is the
defining characteristic of which of the following?
a. Physiologic dependence
b. Codependency
c. Behavioral dependence
d. Tolerance
ANSWER: A
Physiologic dependence is a term used to describe a continuous or intermittent craving for a substance to avoid a
dysphoric or unpleasant mood state.
Option B Codependency is a term that refers to all the behavioral patterns of family members who have been
significantly affected by another family member’s substance or abuse.
Option C Behavioral dependence refers to the substance seeking activities and pathological use patterns of the
person using the substance.
Option D: tolerance refers to the person’s ability to obtain a desired effect from a specific dose of drug.
Reference: Shives. Psychiatric Mental Health Nursing. 7th edition. Page 430
27. Nurse Pitoy documents the following clinical manifestations to be present in a client who is experiencing
cannabis intoxication except?
a. Dry mouth
b. Distortions of time
c. Euphoria
d. Drowsiness
ANSWER: D
The clinical manifestations for cannabis intoxication include dry mouth, euphoria, inappropriate laughter, a
sensation of slowed time, increased appetite and anxiety are also experienced
Reference: Videbeck. Psychiatric Mental Health Nursing. Page 384
28. The following are not priority nursing interventions in caring for a client experiencing flashbacks from
hallucinogenic intoxication except:
a. Try to communicate with and reassure the patient.
c. Providing intrapersonal skills training
b. Exploring with the client relapse triggers
d. Place patient in a protected environment
ANSWER: A
Although options B, C, and D are important interventions in a client experiencing hallucinogenic intoxication, they
are not the priority. Reducing stimuli and the client’s anxiety are the priority nursing intervention for a client
experiencing flashbacks from hallucinogen intoxication.
Reference: Brunner and Suddhart. Medical Surgical Nursing. 10th edition. Page 2172-2173
29. A client presents to the ER complaining of trails of images, moving objects, and flashes of color. The nurse
notifies the doctor that the client has been abusing which of the following substances based on assessment?
a. Cocaine
b. Hallucinogen
c. Opioid
d. Nicotine
ANSWER: B
Hallucinogens cause perceptual disturbances, experiencing trails of images, halos, heightened response to color,
textures and sounds. Options A, C, and D are incorrect.
Reference: Lippincott’s Mental Health and Psychiatric Nursing.4th edition. Page 151
30. The nurse is asked to teach a group of clients in drug rehabilitation clinic on the medical complications of
cocaine abuse. Which of the following should the nurse include in the class?
a. Cardiac arrhythmia
b. Sleepiness
c. Decrease blood pressure
d. Kidney problems
ANSWER: A
Cocaine is a central nervous system (CNS) stimulant that can increase heart rate and blood pressure and cause
hyperpyrexia, seizures, and ventricular dysrhythmias. It produces intense euphoria, then anxiety, sadness,
insomnia, and sexual indifference; cocaine hallucinations with delusions; psychosis with extreme paranoia and
ideas of persecution; and hypervigilance. Chronic psychotic symptoms may persist.
Reference: Brunner and Suddhart. Medical Surgical Nursing. 10th edition. Page 2171
31. Nurse Dorin is admitting a client who has been abusing phencyclidine (PCP) for several months. In planning
for this client’s care, which of the following should be the priority?
a. Provide a well balanced meal
c. Encourage the client to participate in a withdrawal program
b. Teach the client about its complication
d. Ensure client’s safety
ANSWER: D
A client who has been abusing PCP experiences distorted perceptions, hallucinations, and delusions that may
result in the client becoming violent. Ensuring the client safety is the priority. The client has the potential to hurt
oneself or others. Options A, B, and C are all appropriate interventions but not the priority.
Reference: Brunner and Suddhart. Medical Surgical Nursing. 10th edition. Page 2171
Shives. Psychiatric Mental Health Nursing. 7th edition. Page 440
32. Which of the following should the nurse include in her health teaching about smoking cessation program?
a. Nicotine withdrawal clinical manifestations include hot flashes, decreased appetite and muscle cramps
b. The nicotine withdrawal syndrome lasts less than 1 week
c. The nurse’s personal experience with nicotine withdrawal
d. Depression, insomnia and increased appetite may be experienced by the client
ANSWER: D
Nicotine withdrawal causes depression, insomnia, irritability, anxiety, Bradycardia, and increased appetite;
treatment of withdrawal includes use of nicotine gum (Nicorette) or nicotine patch (Nicotrol) in gradually
decreasing doses over a long period of time lasting from 3 weeks to 3 months.
Reference: Lippincott’s Mental Health and Psychiatric Nursing.4th edition. Page 141
33. A mother brings her adolescent son into a clinic and expresses concerns about her son who has been
experiencing slurred speech, muscle weakness, blurred vision, and sense of “high”. Which of the following
questions is a priority for the nurse to ask the adolescent’s mother?
a. “Have you noticed you son inhaling paint and cleaning products?”
b. “Has you son’s school performance declined?”
c. “Has you son seem to spend more time alone?”
d. “How long have you noticed him like this?”
ANSWER: A
The priority question to ask the mother of a child suspected of inhaling substances is if she has noticed the child
inhaling paint or cleaning aerosol products.
Reference: Louise Shives. Psychiatric Mental Health Nursing. 7th edition. Page 440
34. A client who is seeing “dragons in the sky”, hearing dead people’s voices, stating “someone is trying to kill
me” and has a BP of 178/90 was admitted. The nurse assesses this client to be experiencing which of the
following?
a. Morphine withdrawal
b. Amphetamine toxicity
c. Inhalant side effects
d. Alcohol dependence
ANSWER: B
A client who has a toxic level of amphetamines experiences hallucinations (auditory, visual and tacile), severe
paranoia, picking at the face and extremities, and hypertension. Option A: morphine withdrawal, gooseflesh,
yawning, muscle cramps, low back pain. Option C: Inhalant : Euphoria, depressed reflexes, blurred vision
dizziness, incoordination. Option D: The essential feature of alcohol dependence is a cluster of cognitive,
behavioral and physiologic symptoms indicating that the individual continues use of the alcohol despite critical
alcohol-related problems.
Reference: Louise Shives. Psychiatric Mental Health Nursing. 7th edition. Page 436-440
35. A nurse is teaching a new group of inpatients about addiction. The clients say they can stop drinking
whenever they want. These clients still lack the understanding that addiction is a disease in which individuals lose
permanent ability to:
a. Regulate their addictive and impulsive behaviors.
b. Recognize that their addictive behavior is harmful to themselves and others.
c. Act sober even if they are not.
d. Identify with a higher power.
Answer: A
Rationale: The key symptom of addiction is impaired control, or the inability to regulate one’s addictive behavior.
While persons with addiction don’t always recognize consequences of their behavior (option B), it is not because
they lose this ability. Acting sober is an additive behavior (option C). Identifying with a higher power is the next
step after developing understanding of lack of control (option D).
36. The clients in a psycho-education class on addiction express the feeling that they cannot relate with other
clients who do not have the same kind of addictions as they do. The nurse teaches about the similarities and the
differences between process and chemical addictions. The nurse would evaluate that the clients understand the
difference between process addictions and chemical addictions when they say:
a. “Withdrawal is not associated with process addictions.”
b. “Intoxication is not associated with process addictions.”
c. “Tolerance is not associated with process addictions.”
d. “There is a difference between process and chemical addictions.”
Answer: B
Rationale: The DSM-IV describes intoxication as a reversible substance-specific syndrome because of recent
ingestion or exposure to a substance. Withdrawal (option A) and tolerance (option C) can occur for process
addictions even though one may not always think of them as being true for behavioral addiction. Primarily there
is no difference between process and chemical addictions (option D).
37. Upon orientation to the addiction treatment unit the nurse informs the client of the family program and
suggests that the client invite his son to the sessions. The client questions why his 13-year-old son needs to
participate, as he has not seen his father drunk. The nurse’s best response would be:
a. “There generally are no consequences from the addictive behavior because the parent is usually sober when
they are with the children.”
b. “There generally are no consequences from the addictive behavior because the parents are using responsibly
when they are with the children.”
c. “There are generally consequences from the addictive behavior because the child knows they are using even if
they do not see it.”
d. “There are generally consequences from the addictive behavior because parents are impaired whether they are
actively using or recovering from use.”
Answer: D
Rationale: The quality of the parental relationship will be impaired while there is regular dependent drinking
taking place. Alcohol impairs and affects the brain’s capacity to function and cope with activities of daily living.
Children are able to sense the differences in their relationship with their parents when they are drinking or
recovering from its effects; however, the change in relationship is the primary cause of the consequences (option
C). In regard to consequences of use, anyone who has dependent drinking will experience the negative
consequences (options A and B).
38. The nurse provides an in-service on impaired nursing practice. The nurse evaluates teaching as effective
when the staff is able to identify that the most influential risk for impaired nursing practice is that:
a. “Most nurses are adult children of alcoholics or dysfunctional families and are at risk for developing addiction.”
b. “Most nurses have exposure to various substances and believe they are not at risk to develop the disease.”
c. “Most nurses have preconceived ideas about 'what kind of people' get addictions.”
d. “Most nurses are codependent in their personal and professional relationships.”
Answer: B
Rationale: Nurses’ exposure to substances, knowledge about specific effects of certain drugs, and nurses’ belief
that they can handle drug and alcohol use safely to deal with their problems has the greatest impact on the risk
for becoming dependent. Some nurses are adult children of alcoholics (option A) and some may have problems
with codependence (option D), but this does not put them at more risk than those in the general public who have
similar problems. Preconceived ideas about what kind of people become addicted does have a role in risk but not
as great as access (option C).
39. A client comes to day treatment intoxicated, but says he is not. The nurse’s evaluation of his symptomatology
reveals:
a. Denial.
b. Reaction formation.
c. Transference.
d. Countertransference.
Answer: A
Rationale: It would not be unusual for a client who has severe addiction to come to day treatment intoxicated
and deny it. Denial would cause a client to insist he or she is not intoxicated or doesn’t have a problem with
alcoholism despite concrete evidence of the problem. Reaction formation is a defense mechanism that causes
people to act exactly opposite to the way they feel (option B). Transference is the unconscious process of
displacing feelings for significant people in the past onto the nurse in the present relationship (option C).
Countertransference is the nurse’s emotional reaction to clients based on feelings for significant people in the
nurse’s past (option D).
40. A client expresses to the nurse that he feels his family and friends are against him. They have expressed
concern that his continued drinking could be fatal given that he has developed alcoholic cardiomyopathy. The
best response by the nurse would be:
a. “The person expressing concern has a problem with his or her own drinking.”
b. “The person expressing concern has no right to judge another person’s drinking.”
c. “The person expressing concern may be jealous that the client can drink more than they can.”
d. “The person expressing concern has noticed the client’s drinking creates consequences for them.”
Answer: D
Rationale: Concern expressed about drinking is one of the four screening items on the CAGE questionnaire.
Options A, B, and C support the clients belief that others are against him or have no business being concerned.
41. A client who presents in the psychiatric unit tells the admitting nurse she is having a hard time staying sober
and is very depressed. The rationale for treating the depression in a client with substance abuse is:
a. Depression can often keep an individual from working on a recovery program.
b. Depression should be treated only after the client has been sober for 1 month.
c. Depression is a symptom of substance abuse.
d. Depression is an expected outcome of substance abuse recovery.
Answer: A
Rationale: Antidepressant medication and the treatment of depression can enhance sobriety for individuals
suffering from depression. Treating one without the other may result in poor outcomes (option B). Depression
may be a symptom of substance abuse or substance abuse may be a symptom of depression, but this can only
be assessed after a time of sobriety (option C). Depression is common in substance abuse recovery but is not
necessarily an expected outcome (option D).
42. The student nurse has to go to an Pilipinas Alcoholics Anonymous (PAA) meeting as part of the clinical
rotation and report back what he or she finds out about the meeting. The student finds that the Twelve Steps of
PAA teaches that:
a. Once an individual has learned to be sober, they can graduate from the program.
b. Once an individual has learned to be sober, they can remain at risk to use.
c. Acceptance of being an alcoholic will prevent urges to drink.
d. A Higher Power will protect individuals if they feel like using.
Answer: B
Rationale: AA teaches that the alcoholic can never safely return to social drinking and that total abstinence is the
only course for the addiction. When sobriety has been achieved, people don’t “graduate” (option A); they stay
and help others achieve sobriety. Acceptance and Higher Power are active concepts in AA, but practicing these
principles does not remove urges to drink (option C) or guarantee sobriety (option D).
43. The nurse working in obstetrics is reinforcing the physician health teaching about the risks of using
substances during pregnancy. The client states that she only drinks a little beer and wine and would never use
any dangerous drugs. The nurse then assesses for use of which drug that causes the most physical, cognitive,
growth and developmental problems to the fetus?
a. Benzodiazepines
b. Hallucinogens
c. Alcohol
d. Cocaine
Answer: A
Rationale: Alcohol use during pregnancy causes dysmorphic prenatal and postnatal difficulties and CNS
dysfunction. Other substances cause significant health concerns as well, but not quite as many different kinds of
problems (Options B, C and D).
44. A client who was discharged from addiction treatment on disulfiram (Antabuse) medication 3 months ago
returns to the liver service for his follow-up appointment. During the nursing assessment, the nurse prepares the
chart for review and notices the lab work from last week indicates that the GGT is as high as the GGT from his
inpatient addiction treatment. The nurse would infer that the client is:
a. Drinking or experiencing liver problems from the Antabuse.
b. Using marijuana or experiencing liver problems from the Antabuse.
c. Eating fatty foods, is not exercising, or is experiencing problems from the Antabuse.
d. Recently exposed to measles or experiencing problems from the Antabuse.
Answer: A
Rationale: Antabuse and alcohol use cause elevated liver enzymes. Marijuana use (option B), eating fatty foods
(option C), or being exposed to measles (option D) does not cause elevated GGT.
45. The nurse instructs the client about addiction. The nurse determines that the client understands the
instructions given when the client says:
a. “Addiction is a moral disease.”
c. “Addiction is a behavioral habit.”
b. “Addiction is a medical illness.”
d. “Addiction is an emotional attachment.”
Answer: B
Rationale: Alcoholism was officially listed as a disease in 1956 and Jellinek’s identification of the four phases of
disease progression in 1960 reinforced the disease concept. The general public continues to view addiction as a
moral weakness (option A). Addiction does include behavioral habits (option C) and emotional attachment (option
D) but is seen first as a medical disease.
46. A client says he takes a drink every morning to calm his nerves and stop his tremors. The nurse realizes that
the client is at risk for:
a. An anxiety disorder.
b. A neurological disorder.
c. Physical dependence.
d. Psychological dependence
Answer: C
Rationale: Taking a drink in the morning to steady one’s nerves is a sign of physical dependence. With physical
dependence the person begins to drink to avoid withdrawal symptoms. Tremors are one of the ten symptoms of
alcohol withdrawal listed in the Clinical Institute Withdrawal Assessment of alcohol symptoms. People with
anxiety may have tremors, but they wouldn’t be specific to only mornings (option A). Tremors can be due to
movement disorders for which alcohol may suppress the tremors; however, if one had a movement disorder, the
tremors would not just occur in the morning (option B). Psychological dependency is the belief that the client has
to have the substance in order to survive; this client is drinking in the morning to calm his nerves (option D).
47. A young female presents for her school checkup. She denies any medical problems or taking any
medications, but she does acknowledge daily laxative use. As the school nurse, what other symptoms or
problems would you expect to find?
a. Headaches
b. Altered sleep patterns
c. Abnormal eating patterns
d. Intermittent chest pain
Answer: C
Rationale: Laxative abuse is a method used to control weight by anorexics and bulimics. Eating disorder clients
may have cardiac rhythm disturbances but not necessarily chest pain (option D), headaches (option A), or altered
sleep (option B) as a result of their disordered eating.
48. A client with a long history of relapsing from cocaine dependence states he wants to be sober and doesn’t
understand why he keeps thinking about using. Education about the role the Brain Reward System (BRS) plays in
maintaining addiction could help the client understand the disease better. The nurse will evaluate the client’s
understanding of this education if the client states that the role BRS plays is to:
a. Reinforce the use patterns of role models.
c. Facilitate the intoxication process.
b. Mediate job stress and pressure.
d. Facilitate cravings and triggers for re-administration.
Answer: D
Rationale: Cravings appear to be the result of pleasurable memories engendered from the psycho-activating
effect of engaging in addictive behaviors. It’s true that environment and role models influence use patterns, and
that we use addictive behaviors to self-medicate stress and pressure we experience (options A and B). The act of
being intoxicated does not necessarily lead to thought, triggers, or urges to use (option C).
49. A client is asking about the detoxification process and withdrawal from a benzodiazapine. The best response
by the nurse is that the client will:
a. Be placed on a rapid detoxification schedule.
b. Experience the start of withdrawal immediately upon discontinuation.
c. Be placed on a similar medication for detoxification.
d. Sleep almost continuously for the first 24 hours.
Answer: C
Rationale: Withdrawal from depressants is generally treated by substitution with a longer-acting drug in the same
class. Clients are usually medicated on a fixed schedule dosing pattern or a symptom triggered approach with the
client receiving a specific dose of medication depending on the severity of the withdrawal symptoms. Onset of
withdrawal symptoms and the time it takes to complete withdrawal would depend on the half-life of the
benzodiazepines on which the client depends. The symptoms from depressants are activating kinds of symptoms
such as nausea, vomiting, and tremor. Withdrawal symptoms are generally the opposite symptoms of the drug
someone is addicted to.
50. A nurse is assigned to five clients in various stages of inpatient treatment today. In caring for a chemically
dependent client requiring acute care, the nurse’s primary role is to:
a. Deliver psycho-education on the dangers of drug and alcohol use.
b. Review the problems in the client’s relapse prevention plan.
c. Facilitate administration of anti-craving medications.
d. Monitor and provide withdrawal care based on unit protocol.
Answer: D
Rationale: Acute care is defined as care of the client experiencing intoxication and withdrawal. Beginning
education about the disease (option A) and interventions (options B and C) to help someone stay sober are
introduced at the end of the active phase and become the focus of treatment during the rehabilitative phase of
treatment.
51. A client with chronic headaches is detoxifying from alcohol and will require medications to treat the
withdrawal. When assessing the client’s withdrawal symptoms the priority of nurse would be to assess:
a. The level of pain the client is experiencing according to the pain scale.
b. The difference between the client’s current level of pain and the usual level of pain.
c. Whether the client is experiencing more pain than usual because of tolerance.
d. The defense mechanisms the client uses and how that influences the level of pain.
Answer: B
Rationale: Headaches are a symptom of detoxification from alcohol. A client with chronic headaches would be
expected to have headaches so the nurse would need to assess the difference between the pain level of usual
headaches and the withdrawal headaches. Initially, assessment of pain using the pain scale will not provide the
difference between the types of pain (option A). Clients experiencing pain, who are addicted may need more pain
medication than the non-addicted client because of tolerance regardless of level of pain (option C). How an
individual appraises the symptoms of stress could influence defense and coping mechanisms they might use, but
it wouldn’t be specific to the one symptom of pain (option D).
52. A nursing educator is teaching a group of community health nurses on moderating alcohol use. The nurse
educator evaluates the group’s understanding of “harm reduction” if the group is able to identify which group is
not appropriate for “harm reduction”?
a. Individuals with tolerance
c. Individuals unable to control use
b. Individuals with alcohol abuse
d. Individuals with high-dose use
Answer: C
Rationale: Clients who are unable to control their use or are unable to learn strategies to reduce intake and/or
harm caused by their use, are not good candidates for this approach. People with tolerance (option A), alcohol
abuse (option B), and high dose use (option D) may be successful in decreasing the frequency and quantity of
alcohol they drink.
53. Some adolescent clients relapse because they feel pressured by their peers. Which skill training could the
nurse plan for adolescents in order to assist them in relapse prevention?
a. Vocational skills
b. Drinking refusal skills
c. Problem-solving skills
d. Communication skills
Answer: B
Rationale: The quality of an adolescent’s recovery environment can be helpful or hurtful to someone attempting
to maintain sobriety. Friends or acquaintances may encourage a recovering person to use. The recovering
adolescent may want to refuse, but may not know how. Behavioral rehearsal, saying “no thanks” to an offer to
engage in addictive behavior, can increase a recovering person’s confidence. Vocational skills will not help the
adolescent to refuse a drink (option A). Problem solving skills (option C) and communication skills (option D) may
be useful but not as helpful as skills directly related to refusing to drink.
54. A family member identified a drinking problem in your client. This client was admitted to the medical unit for
chest pain and is undecided regarding the desire for chemical dependence treatment suggested by the addiction
consultation team. An additional nursing diagnosis for the client would be:
a. Impaired family process: alcoholism.
b. Ineffective management of therapeutic regimen: individual.
c. Risk for injury: potential for relapse.
d. Decisional conflict.
Answer: D
Rationale: The definition for decisional conflict is uncertainty about a course of action to be taken when choice
among competing actions involve risk, loss, or challenge to personal life values. Impaired family process:
alcoholism, may apply, but it is more appropriate for the family than the individual (option A). Ineffective
management of therapeutic regimen (option B) and risk for injury (option C) imply that the client has already
made a commitment to recovery.

SITUATION: Nurse Hannah, a supervisor in a tertiary hospital, noticed that Nurse Juvy is often absent and
comes late to work. When on duty, Nurse Juvy spends more time in the bathroom, and is frequently involved in
incidents in which, her clients report they haven’t received relief for pain; although documentation indicates that
they have received the prescribed medications.
55. Based on Nurse Hannah’s observation, Nurse Juvy is described to be which of the following?
a. A sluggish nurse
b. An impaired nurse
c. A model nurse
d. An irresponsible nurse
ANSWER: B
Nurses like the rest of the community, can suffer from substance abuse or dependence. Many impaired nurse are
not aware that they have problems, and resists any offer of support or help. The following actions by the nurse
should be considered as possible impairment behavior: volunteers to work overtime frequently especially on
weekends when staffing ratios are less than during the weekends, Leaves the floor or unit frequently or spends
considerable time in the bathroom, frequently involved in incidents in which clients report they haven’t received
relief for pain although documentation indicates that they have received prescribed medications. Exhibits lapses
in memory, changes in personal appearance, and appears preoccupied, gives questionable explanations regarding
drug wastage and discrepancies in documentation. Options A, C, and are incorrect.
Reference: Louise Shives. Psychiatric Mental Health Nursing. 7th edition. Page 443
SITUATION: Substance abuse is known to cause host of problems for individual users, their communities, and
society as a whole. Its cost is staggering, as evidenced by the lost of productivity, medical illness, serious
injuries, and premature death.
56. The nurse should monitor which of the following for a client experiencing alcohol withdrawal?
I. Hypertension
II. Sedation
VI. Startles easily
II. Tiniitus
IV. Tachycardia
V. Pupil constriction
a. I, V, VI
b. I, II, III
c. I, IV, VI
d. IV, V, VI
ANSWER: C
An increase in blood pressure and an increase in pulse are the most prevalent and first clinical manifestations
experienced by the client in alcohol withdrawal. Other clinical manifestations include irritability, a sense of being
hyperactive, startling easily, making jerky movements, anxiety, insomnia, and tremors.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 544-545
57. A client is experiencing late signs of heroin withdrawal. Which of the following would Nurse Hannah expect to
assess from the client?
a. Restlessness & Irritability
c. Vomiting and Diarrhea
b. Yawning & diaphoresis
d. Constipation & steatorrhea
ANSWER: C
Vomiting and diarrhea are usually the late signs of heroin withdrawal, along with muscle spasm, fever, nausea,
repetitive, abdominal cramps and backache.
Reference: Videbeck, Sheila L. Psychiatric Mental Health Nursing, 2nd edition, Page 415
58. To minimize the severe physical discomforts of client undergoing opiate withdrawal, they are given which of
the following medications?
a. Barbiturates
b. Amphetamines
c. Methadone
d. Benzodiazepines
Answer: C
Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central
nervous system but doesn’t have the same deleterious effects as other opiates, such as cocaine, heroin, and
morphine. Barbiturates, amphetamines, and benzodiazepines are highly addictive and would require
detoxification treatment.
Reference: Ann Isaacs. Mental Health and Psychiatric Nursing. 4th edition. Page 155
59. A client admitted for detoxification of cocaine overdose tells the nurse that she frequently uses cocaine and
that she can control cocaine use if she wishes to do so. What coping mechanism is she using?
a. Denial
b. Withdrawal
c. Repression
d. Logical thinking
Answer: A
Denial is unconscious defense mechanism in which emotional conflict and anxiety is avoided by refusing to
acknowledge feelings, desires, impulses, or external facts that are consciously intolerable. Withdrawal is a
common response to stress, characterized by apathy. Logical thinking is the ability to think rationally and make
responsible decisions, which would lead the client admitting the problem and seeking help. Repression is
suppressing past events from the consciousness because of guilty association.
Reference: Videbeck. Psychiatric Nursing. 2nd edition. Page 51
60. A male client was admitted to the mental health unit because of prolonged feeling of depression about the
loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol
12 hours ago. His vital signs are the following: temperature, 100° F, pulse 100, and BP 142/100. The nurse plans
to give the client lorazepam (Ativan) based on which of the following priority nursing diagnosis?
a. Risk for injury related to suicidal ideation.
c. Knowledge deficit related to ineffective coping.
b. Risk for injury related to alcohol detoxification.
d. Health seeking behaviors related to personal crisis.
ANSWER: B
The most important nursing diagnosis is related to alcohol detoxification (option B) because the client has
elevated vital signs, a sign of alcohol detoxification. Maintaining client safety related to (Option A) should be
addressed after giving the client Ativan for elevated vital signs secondary to alcohol withdrawal. (Options C and
D) can be addressed when immediate needs for safety are met
Reference: Shives. Psychiatric Mental Health Nursing. 7th edition. Page 437-438
SITUATION: Vecky Mae, a mother of two, was referred to a mental health clinic. She complains of frequent
exhaustion. Fatigue and anxiety was ruled out by the doctor.
61. During the initial assessment, Nurse Habibi suspects that Vecky Mae may be experiencing a situational crisis.
Which of the following questions would be most effective to explore this possibility?
a. “Could you tell me all about yourself?”
b. “Do you think your symptoms are related to a recent event in your life?”
c. “Do you think the symptoms are the ones causing the problem?’
d. “What happened to you recently?”
ANSWER: D
Crisis intervention focuses on identifying and solving the patient’s immediate presenting problem. By asking
about recent changes in the patient’s life, the nurse tries to identify factors related to the problem. It is too early
in the therapeutic relationship to ask the patient to link her present symptoms to recent life changes. Such
analysis needs further exploration and should be based on trust established in the nurse-patient relationship.
Because the patient is seeking an answer to her problem, asking her to identify what is causing the symptoms is
not helpful. Complete diagnostic assessments typically include extensive explorations of the past and are not
done in crisis intervention.
Reference: Ann Isaacs. Mental Health and Psychiatric Nursing. 4th edition. Page 225-227
: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 804
62. The nurse’s role in crisis therapy should be which of the following?
a. Nondirective and passive
b. Firm and confrontational
c. Active and directive
d. Calm and non-expressive
ANSWER: C
Because crisis intervention aims for quick resolution of a patient’s immediate problem, the nurse must take an
active and directive role in this treatment intervention. By using creativity and remaining flexible and open to
various therapeutic approaches, the nurse can actively guide the patient through her crisis. A non-directive,
passive approach is inappropriate because it fails to recognize that a patient in crisis is in turmoil and needs the
direction of others. Being firm may be necessary; however, being confrontational is unwise because it can
exacerbate the patient’s anxiety. Although remaining calm is an asset, being non-expensive is non-therapeutic.
Reference: Ann Isaac. Mental Health and Psychiatric Nursing. Page 226
63. When working with a client in crisis, which of the following is MOST important?
a. Assisting the client in determining what is similar about this crisis to the previous crises in his life
b. Remaining focused on the client’s immediate problem
c. Obtaining a complete assessment of the client’s past history
d. Determining whether the client may have a part on the occurrence of the crisis
ANSWER: B
The nurse must remain focused on the client’s immediate problem as there is not enough time and no need to
delve into the complete past history of the client. Option D is not relevant at this time although it may be more
important in learning to prevent future crisis situations. Option A may be the next usual step after Option B.
Reference: Ann Isaac. Mental Health and Psychiatric Nursing. Page 226
64. A crisis intervention nurse meets with a young client who was admitted after attempting suicide by slashing
her wrists. The nurse’s initial goal at this time is to:
a. Determine the precipitating event, determine how many people are involved in the incident and determine how
angry the client is
b. Determine if the client has an immediate support system, determine what the people in the support system
think of the client cutting the wrists and determine the level of anger of the client
c. Determine the precipitating event, determine if the client has an immediate support system and assess the
likelihood of the immediate recurrence of the suicidal act
d. Assess the likelihood of the suicidal act, determine what made the client angry the determine how angry the
client is
ANSWER: C
It incorporates all the information a crisis intervention nurse needs immediately.
Option A and B are incorrect because the nurse does not need to know about other people’s involvement at this
time.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 806-810
SITUATION: Nurses encounter survivors for abuse in all health care settings. For this reason, nurses must be
knowledgeable about abuse.
65. Sadjoy, a college student, is required to submit a case study. She chooses the topic child abuse. Which
among the following is the most common form of child abuse?
a. Physical abuse
b. Child neglect
c. Sexual abuse
d. Emotional abuse
ANSWER: B
Child neglect is the most common form of child abuse reported. There are several types of neglect: failure to
protect a child includes failure to prevent various kinds of accidental injury, such as ingestion of poison, electric
shocks, falls, and burns. Physical neglect includes failure to provide food, clothing, and shelter. Medical neglect
includes failure to provide for the child’s medical needs. Option A: Physical abuse may include spanking, hitting,
kicking, shoving, or any other type of physical action directed toward the child that results in nonaccidental
injury. Option C: Sexual abuse includes fondling a child’s genitalia, intercourse, incest, rape, sodomy,
exhibitionism, and commercial exploitation through prostitution or the production of pornographic material.
Option D: Emotional abuse includes acts or omissions that psychologically damage the child. Emotional abuse
severely affects child’s self-esteem and often leaves a permanent emotional scar.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 846
Reference: Videbeck. Psychiatric Mental Health Nursing. 3rd edition. Page 201
66. The law that protects children from abuse:
a. R.A. 3310
b. R.A. 6425
c. R.A. 7610
d. R.A. 7160
ANSWER: C
RA 7610 is the “Special Protection of Children against Abuse, Exploitation and Discrimination Act.". RA 6425:
Dangerous drug act. RA 7160: Local government code. RA 3310: no such thing.
Reference: Venzon. Professional Nursing in the Philippines. 10th edition. Page. 449
67. A child is admitted to the pediatric unit with multiple bruises and abrasions with vague answers to questions
on occurrence. The nurse suspects the child has been abused. The nurse’s primary responsibility must be to:
a. Treat the child’s injury
c. Protect the child from any further abuse
b. Confirm the suspected child abuse
d. Have the child examines by the doctor
ANSWER: C
Most injuries to abused children aren’t life threatening; protection takes priority over immediate treatment.
Option A: the doctor’s primary responsibility is treatment of medical injuries. Option B: An accurate diagnosis of
child abuse takes time and must fully investigated. Option D: The nurse is often the first individual to see the
abused child and must establish protection even before the doctor arrives.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 846, 861
68. The nurse is assessing a parent who abused her child. Which of the following risk factors would the nurse
suspect to find in this case?
a. Flexible role functioning between parents
c. Single parent home situation
b. History of parent having been abused as child
d. Presence of parental mental illness
ANSWER: B
One of the most important risk factors is history of childhood abuse in the parent who abuses. Family violence
follows a multigenerational pattern. Parents who are flexible in their roles are characteristic of healthy
functioning, not abuse. Single parent households and a history of mental illness are not established risk factors
for child abuse by a parent.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 865-866
69. Incidents of a child molestation that come out years later when the victim is an adult are best explained the
ego defense mechanism of:
a. Repression
b. Regression
c. Rationalization
d. Reaction formation
ANSWER: A
Repression is a coping mechanism in which unacceptable feelings are kept out of conscious awareness; later
under stress or anxiety, thoughts or feelings surface and come into one’s conscious awareness
Reference: Videbeck. Psychiatric Mental Health Nursing. 3rd edition. Page 51-52
70. When working with children who have been sexually abused by a family member, it is important for the nurse
to understand that these victims usually are overwhelmed with feelings of:
a. Humiliation
b. Confusion
c. Self blame
d. Hatred
ANSWER: C
Victim of child abuse leads to disturbance in growth and development (beginning with trust and autonomy
issues), ambivalence about the experience (both benefit and pain) and denial of what had happened. The young
child is fulfilling the roles of a child and lover to the perpetrator, and roles of child and protector to the rest of the
family (protecting them from the horrible secret) As a result the child begins a long term process of taking care of
others to the exclusion of personal needs. Basically the child wishes for love not sex but eventually feels guilty,
exploited, betrayed, angry, dirty, helpless, and responsible.
Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 614
71. A nurse working in the emergency department is conducting an interview with a victim of spousal abuse.
Which step should the nurse take first?
a. Contact appropriate legal service
b. Ensure privacy for interviewing the victim away from the abuser
c. Establish rapport with the victim and abuser
d. Call security guard
ANSWER: B
Privacy away from the abuser is important. This allows the victim to discuss the problem freely, without fear of
reprisal from the abuser. Option A: It is not the responsibility of the nurse to call the legal service, it is up to the
woman to make that decision. However if injury is inflicted the nurse is obligated to report the abuse. Option C:
Although the nurse would want to establish rapport with the victim, her initial concern would not be to establish
rapport with the abuser. The situation does not describe the abuser as currently violent, requesting a security
is inappropriate at this time.
Reference. Ann Isaacs. Psychiatric Nursing. Page 175
72. What are the common defense mechanisms used by abused victims?
a. Undoing, Reaction formation, displacement
c. Repression, suppression, denial
b. Denial, projection, Undoing
d. Displacement, Substitution, compensation
ANSWER: C
Denial, repression, suppression, rationalization and dissociation are common defense mechanisms used by the
victims to cope with this no-min situation. The more severe the abuse the more likely the repression will begin
near puberty. Repression normally lasts until the victims are in their 20’s or 30’s and are having trouble with
intimate relationships and/or parenting.
Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 614
73. All but one are typical manifestations of adult clients with history of sexual abuse during childhood?
a. They resolve to self mutilation.
b. They have trouble having intimate relationships
c. They often remember what had happened
d. Ambivalence is common especially if the perpetrator is a family member
ANSWER: C
Repression of the memories is common in victims of childhood sexual abuse. The memories might return
gradually in pieces or in a sudden overwhelming flood. Victims cannot be rushed to remember the abuse before
they are ready to cope. Option A: Self mutilation is a common way of dealing with the emotional pain, loss, rage
and abandonment. Option B: Healthy adult relationships and sexual intimacy are difficult because of problems in
trusting anyone and the history of linking abuse and love. Option D: Intense anger and ambivalence happens
when the perpetrator is a family member because victim is still seeking approval and love from the perpetrator.
Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 616-618
74. A client who has a history of sexual abuse is admitted to the psychiatric unit for self-mutilation. She is found
sucking her thumb while in bed. The nurse recognizes that this behavior demonstrates which coping mechanism?
a. Fantasy
b. Regression
c. Displacement
d. Compensation
ANSWER: B
Regression is a coping mechanism in which a client returns to an earlier, less threatening level of adaptation
(development). Displacement is the discharge of pent-up feelings onto something or someone else less
threatening than the original source of the feelings. Fantasy is the gratification of frustrated desires,
achievement, and relationships by substituting them with daydreams and imagery. Compensation is excelling in
one area to counterbalance deficiencies in another area.
Reference: Fortinash. Psychiatric medical health nursing. 3rd edition. Page 9-10
75. What is the priority nursing intervention for a child or elder victim of abuse?
a. Assess the scope of the abuse problem
c. Implement measures to ensure the victim’s safety
b. Analyze family dynamics
d. Teach appropriate coping skills
ANSWER: C
Establishing the safety of the victim is a priority. The question is asking about implementing a specific nursing
action, not assessing the problem or analyzing the family dynamics. Teaching coping skills is important, however
the priority action involves ensuring safety.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 861
76. Nurse Bing provides teaching to nursing students, and the topic is about elder abuse. Nurse Bing helps the
nursing students identify that which client is most typical of a victim of abuse?
a. A 74 year old man with moderate hypertension
c. A 91 year old woman with advanced Parkinson’s disease
b. A 67 year old man with newly diagnosed cataracts
d. A 70 year old woman with diagnosis of Pneumonia
ANSWER: C
Elder abuse is widespread and occurs among all subgroups of the population. Elder abuse includes physical and
psychological abuse, misuse of property, and violation of rights. The typical abuse victim is a woman of advanced
age with few social contacts and at least one physical or mental impairment that limits her ability to perform
activities of daily living. In addition, the client usually lives alone or with the abuser and depends on the abuser
for care.
Reference: Workman, M. .Medical-surgical nursing: Critical thinking for collaborative care. 5th edition. Page 4849
77. The nurse is talking with a client who just had a beautiful bouquet of roses delivered. Suddenly the client
becomes tearful and stares out the window. The client has history of sexual abuse. Which of the following should
the nurse include in the plan of care for this client?
a. Tell the client that sexual abuse was in the past
c. Give the client some time alone and return later
b. Tell the client to relax and enjoy the rose
d. Assess if the client is having flashback
ANSWER: D
Clients who have experienced traumatic event such as sexual abuse may experience flashbacks. The triggers for
these flashbacks may be visual, auditory, tactile, or olfactory
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 428
SITUATION: Rape is not just a physical aspect; it's a rape of the mind of the victim. Rape implies that the victim
is worthless and that it's their fault that they provoked it.
78. An 18-year-old female was sexually attacked while on her way home from work. She is brought to the
hospital by her mother. Rape is an example of which type of crisis?
a. Situational
b. Adventitious
c. Developmental
d. Internal
ANSWER: B
Adventitious crisis is a crisis involving a traumatic event. It is not part of everyday life. A. Situational crisis is
from an external source that upset ones psychological equilibrium Option C and D. Are the same. They are
transitional or developmental periods in life
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 804
79. During the initial care of rape victims the following are to be considered EXCEPT:
a. Assure privacy.
c. Accompany the client in the examination room.
b. Touch the client to show acceptance and empathy
d. Maintain a non-judgmental approach.
ANSWER: B
The client finds touch intrusive and therefore should be avoided. A. Privacy is one of the rights of a victim of
rape. C.The client is anxious. Accompanying the client in a quiet room ensures safety and offers emotional
support. D. Guilt feeling is common among rape victims. They should not be blamed
Reference: Shives. Psychiatric Mental Health Nursing. 7th edition. Page 139
80. The nurse acts as a patient advocate when she does which of the following?
a. She encourages the client to express her feeling regarding her experience.
b. She assesses the client for injuries.
c. She postpones the physical assessment until the client is calm
d. Explains to the client that her reactions are normal
Answer: C
The nurse acts as a patient advocate as she protects the client from psychological harm. Option A The nurse acts
as a counselor. Option B The nurse acts as a technician. Option D this exemplifies the role of a teacher
Reference: Shives. Psychiatric Mental Health Nursing. 7th edition. Page 145
81. Which of the following will be the primary goal for rape victim clients in crisis intervention?
a. To assist the client to express her feelings
c. To support her adaptive coping skills
b. To help her identify her resources
d. To help her return to her pre-rape level of function
Answer: D
The goal of crisis intervention to help the client return to her level of function prior to the crisis. Options A,B and
C are interventions or strategies to attain the goal
Reference: Ann Isaacs. Psychiatric Mental Health Nursing. 4th edition. Page 226
82. Five months after the rape incident the client complains of difficulty to concentrate, poor appetite, inability to
sleep and a feeling of guilt. She is likely suffering from which of the following?
a. Adjustment disorder
c. Generalized Anxiety Disorder
b. Somatoform Disorder
d. Post traumatic disorder
Answer: D Post traumatic disorder
Post traumatic stress disorder is characterized by flashback, irritability, difficulty falling asleep and concentrating
following an extremely traumatic event. This lasts for more than one month .Option A: Adjustment disorder is the
maladaptive reaction to stressful events characterized by anxiety, depression and work or social impairments.
This occurs within 3 months after the event. Option B: Somatoform disorders are anxiety related disorders
characterized by presence of physical symptoms without demonstrable organic basis. Option C Generalized
anxiety disorder is characterized by chronic, excessive anxiety for at least 6 months
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 428-429
83. A woman arrives in the Emergency Center and tells the nurse that she thinks she has been raped. The client
is sobbing and expresses disbelief that a rape had happened because the man is suppose to be her best friend.
After acknowledging the client's fear and anxiety, how should the nurse respond?
a. “I would be very upset and mad if my best friend did that to me.”
b. “You must feel betrayed, but maybe you might have led him to commit the act?”
c. “Rape is not limited to strangers and frequently perpetrated by someone who is known to the victim.”
d. “This does not sound like rape. Did you change your mind about having sex after the fact?”
ANSWER: C
A victim of date rape or acquaintance rape is less prone to recognize what is happening because the incident
usually involves persons who know each other and the dynamics are different than rape by a stranger. Option C
provides confrontation for the client's denial because the victim frequently knows and trusts the perpetrator.
Nurses should not express personal feelings (Option A) when dealing with victims. Suggesting that the client led
on the rapist (option B) indicates that the sexual assault was somehow the victim’s fault. Option D is judgmental
and does not display compassion or establish trust between the nurse and the client.
Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 610-611
84. The mental health nurse is assessing a family experiencing violence. Which factor would the nurse initially
address in the assessment?
a. The family’s anger toward the abuse
c. The family’s current ability to use community resources
b. The coping style of each family member
d. The family’s denial of the violent nature of the abuser’s behavior
ANSWER: B
The initial family assessment should focus on a careful history of each family member. Once the coping style of
each family member is known then other factors can be assessed. How an individual family member copes will
determine how the individual will deal with the abusive situation. Although options a, c, and d are a component of
the assessment, they are not the initial focus.
Reference: Antai-Otong. Psychiatric Nursing: Biologic and Behavioral concept 2nd edition
85. To successfully and appropriately work with a woman victimized by physical abuse, the nurse would first:
a. Agree with the woman that it is possible that she might have acted in a manner that provoked the abuse
b. Carefully examine his or her own personal attitudes toward the victim and abuser before working with the client
c. Establish firm time line for the woman to make the necessary changes in her situation
d. Reinforce with the woman that dealing with the psychological and physical aspects is of the priority
ANSWER: B
The nurse must work through her or his personal fears and prejudices in order to be an advocate and to
effectively identify and interact therapeutically with victims of physical violence. The nurse who agrees with the
client (option a) is fostering the notion that the victim is at fault. If the nurse establishes time lines for the victim
(option c) or tells the victim that physical and psychological issues should be dealt with first (option d), the nurse
becomes a controller. Each of these is inconsistent with the right of the client to self-determination and
competent nursing care.
Reference: Antai-Otong. Psychiatric Nursing: Biologic and Behavioral concept 2nd edition
86. A nurse is assigned to care for an older client who has been identified as a victim of physical abuse. In
planning care for this client, the nurse’s priority is focused toward:
a. Referring the abusing family member for treatment
c. Encouraging the client to file charges against the abuser
b. Investigating the occurrence of abuse
d. Removing the client from any immediate danger
ANSWER: D
Priority: Safety of the client first
Whenever a client has been identified as a victim of abuse, priority must be placed on ascertaining whether the
person is in any immediate danger. If so, emergency action must be taken to remove the person from the
abusing situation.
87. Mental health clinicians working from an ecological theoretical perspective would suggest violent behavior is:
a. A neurologically based instinctual drive
b. A part of the socialization process
c. A basic instinct of displaced self-destructive impulses
d. Influenced by interactions among personal predisposition, relationships, community, and society
ANSWER: D
An ecological perspective is based on the belief that violent behavior is influenced by interactions among personal
predisposition, relationships, community, and society. Biological theories suggest that violence is a neurologically
based instinctual drive. The psychoanalytic perspective of violence suggests that violence is a basic instinct of
displaced and self-destructive impulses. Social learning theorists hypothesize that violence is a part of the
socialization process.
Reference: Antai-Otong. Psychiatric Nursing: Biologic and Behavioral concept 2nd edition
SITUATION: Many substances can be used and abused; some can be obtained legally while others are illegal.
These include alcohol and prescription medications as substances that can be abused.
88. A family system’s explanation for substance abuse would include which of the following statements?
a. Addiction can be managed through pharmacologic intervention.
c. Addiction is due to genetic causes.
b. Addiction shifts the family focus.
d. Addiction is a disease.
ANSWER: B
A family systems explanation for substance abuse would assess whether the addiction is serving a purpose for
the family. The addiction may shift the family's focus and distract them from other issues. The explanation that
addiction is a disease, is related to genetics, or can be pharmacologically managed is a biologic/genetic approach.
Reference: Kneisl. Contemporary Psychiatric Mental Health Nursing 2nd edition
89. Which of the following nursing diagnoses receives priority for a client in alcohol withdrawal?
a. Ineffective coping
c. Disturbed sensory perception
b. Disturbed thought processes
d. Risk for injury
ANSWER: D
A client in alcohol withdrawal is at risk for injury from delirium tremens. Death from delirium tremens can occur
from volume depletion, electrolyte imbalance, or cardiac arrhythmia. Disturbed thought processes and disturbed
sensory perceptions are diagnoses used for delusions, hallucinations, and illusions that may occur during delirium
tremens. Ineffective coping is a diagnosis used for substance abuse.
Reference: Kneisl. Contemporary Psychiatric Mental Health Nursing 2nd edition
90. An adolescent is brought to the emergency room by a parent. The assessment reveals that the client has
been acting strangely for the past 3 hours and is hypervigilant, grandiose, and irritable. Vital signs indicate
hypertension, tachycardia, and some arrhythmias. The client may have ingested:
a. Crack
b. Amphetamines
c. Cocaine
d. Alcohol
Answer: B
Amphetamine intoxication includes symptoms of hypervigilance, grandiosity, and irritability. Crack and cocaine
are the same drug in different forms. Their effects are the same as amphetamines, but are shorter acting. Alcohol
intoxication includes a relaxed euphoria, lack of concentration, and decreased inhibitions.
Reference: Kneisl. Contemporary Psychiatric Mental Health Nursing 2nd edition
91. When interviewing a person for possible admission to the substance abuse treatment unit, you find the client
saying that the drinking is just social and not a problem, and that the admission is just to satisfy the spouse who
is threatening annulment. The spouse describes the amount of drinking as sufficient enough to cause work to be
missed at least 1 day a week and to have resulted in the third charge of driving while intoxicated. The nurse
suspects that this discrepancy in stories is due to the client’s using which of the following defense mechanisms?
a. Lying
b. Denial
c. Rationalization
d. Undoing
ANSWER: B
Denial is a common defense mechanism used by those addicted to substances. It is often said to be the most
frequently used defense mechanism of the abuser or addict. Denial is an unconscious defense mechanism that
allows the client to minimize or disconnect from the reality of the negative impact of chemical use.
Reference: Kneisl. Contemporary Psychiatric Mental Health Nursing 2nd edition
92. A client voluntarily admits himself to the substance abuse unit. He confesses that he drinks a few glasses of
tequila each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol
withdrawal. What are some early signs of this condition?
a. Vomiting, diarrhea, and bradycardia
b. Dehydration, temperature above 101° F (38.3° C), and pruritus
c. Hypertension, diaphoresis, and seizures
d. Diaphoresis, tremors, and nervousness
ANSWER: D
Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic hallucinosis, and alcohol withdrawal delirium
(formerly delirium tremens). Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea,
vomiting, malaise, increased blood pressure and pulse rate, sleep disturbance, and irritability. Although diarrhea
may be an early sign of alcohol withdrawal, tachycardia — not bradycardia — is associated with alcohol
withdrawal. Dehydration and an elevated temperature may be expected, but a temperature above 101° F
indicates an infection rather than alcohol withdrawal. Pruritus rarely occurs in alcohol withdrawal. If withdrawal
symptoms remain untreated, seizures may arise later.
93. A nurse is evaluating an adult client from the substance abuse unit. Which statement by the client reveals
that he client may be ready for discharge?
a. “I’ll take my Antabuse when I need it”
c. “I’ll drink in moderation and only on the weekend”
b. “I can’t wait to hang out with my old friends”
d. “Attending daily AA meetings will help me not drink again”
ANSWER: D
Daily attendance at AA meetings is necessary for most discharged clients to remain sober and continue their
rehabilitation. Antabuse is taken daily for 1 to 2 weeks, not on a prn basis. Option B: hanging out with old friends
increases the likely hood of ingesting alcohol. Option C: The goal of rehabilitation is to abstain from alcohol.
Reference: Norman Keltner. Psychiatric Nursing 5th edition
94. A student with history of barbiturate addiction is brought to the ER with suspected overdose. Which of the
following assessments is the nurse likely to make?
a. Watery eyes, slow and shallow breathing, clammy skin
b. Dilated pupils, shallow respirations, weak and rapid pulse
c. Constricted pupils, respirations depressed, nausea
d. Responsive pupils, increased respirations, increased pulse and blood pressure
ANSWER: B
The effects of overdose of barbiturates are shallow respirations, cold and clammy sin, dilated pupils, weak and
rapid pulse, coma and possible death.
Reference: Norman Keltner. Psychiatric Nursing 5th edition
SITUATION: Child abuse is harm to, or neglect of, a child by another person, whether adult or child. Child abuse
happens in all cultural, ethnic, and income groups. Child abuse can either be physical, emotional - verbal, sexual
or through neglect. Abuse may cause serious injury to the child and may even result in death.
95. While assessing a 3-year-old boy, Nurse Hannah notices several small, round burns on his legs and trunk that
looked like cigarette burns. Nurse Hannah suspects physical abuse. Which parental behavior provides the
greatest validation for such suspicions?
a. The parents' explanation of how the burns occurred is different from the child's explanation of how they
occurred.
b. The parents seem to dismiss the severity of the child's burns, saying they are very small and have not posed
any problem.
c. The parents become very anxious when the nurse suggests that the child may need to be admitted for further
evaluation.
d. The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's
observation of the type of burn.
Answer: D
Option D provides the most validation. The parent's explanation (subjective data) is incompatible with the
objective data (small round burns on the legs and trunk). Option A provides only subjective data, and the child's
explanation could be influenced by factors such as age, fear, or imagination. The parent's apparent lack of
concern (option B) is inconclusive, but the nurse's opinion of the parents' reaction is subjective and could be
wrong. Option C might provide a clue that child abuse occurred, but the nurse must remember that most parents
are anxious about their child being hospitalized.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 846-847
96. A nurse, working in the emergency room of a children's hospital, admits a child whose injuries could have
resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected
child abuse?
a. The nurse should obtain objective data such as x-rays before reporting suspicions to the authorities.
b. The nurse should confirm any suspicions of child abuse with the healthcare provider before reporting to the
authorities.
c. The nurse should report any case of suspected child abuse to the nurse in charge.
d. The nurse should note in the client's record any suspicions of child abuse so that a history of such suspicions
can be tracked.
Answer: C
It is the nurse's legal responsibility to report all suspected cases of child abuse. Notifying the charge nurse starts
the legal reporting process (Option C).
Reference: Ann Isaacs. Psychiatric Mental Health Nursing. 4th edition. Page 175
SITUATION: Rape and sexual assault, whether by a stranger or a friend, is never the woman's fault. Rape and
sexual assault is always more about the use of force or power to humiliate, control, hurt or violate a woman than
about sexual desire or passion. There is evidence to suggest that a very large number of attacks are
premeditated. The appearance of the woman in terms of status, age, cultural background, occupation, previous
relationships is irrelevant; any woman can suffer sexual assault or rape.
97. A client who has been raped tells the nurse that the rape was her fault because she walked down an alley on
her way to school. Which response by the nurse would be best in this situation?
a. Accept the client’s statement that this was risk-taking behavior
b. Ask the client what other behaviors may have been risky
c. Emphasize that the rapist, not the client is responsible
d. Suggest that the client discuss this issue later
ANSWER: C
The client’s feeling of self-blame is a common response to rape-trauma crisis. However, this is not realistic
perception of the event, and the nurse should point out reality (telling the victim that the rapist is responsible).
The responses in options A and B would only serve to reinforce the client’s misperception that her own behavior
caused the rape and, therefore, are incorrect. The response in option D is incorrect because it avoids addressing
the client’s distress and is unsupportive to the situation.
Reference: Norman Keltner. Psychiatric Nursing. 5th edition. Page 612-613
98. A female victim of sexual assault is being seen by Nurse Hannah. The client states that she still feels “as
though the rape just happened yesterday”, even though it has been a few months since the incident. The
appropriate nursing response is which of the following?
a. “You need to be realistic. The rape did not just occur”
b. “It will take some time to get over these feelings about your rape”
c. “Tell me more about the incident that causes you to feel the rape just occurred”
d. “What do you think that you can do to alleviate some of your fears about being raped again”
ANSWER: C
Option C allows the client to express her ideas and feelings more fully, and portrays a nonhurried,
nonjudgmental, supportive attitude on the part of the nurse. Clients need to be reassured that their feelings are
normal and that they may express their concerns freely in a safe, caring environment. Option D places the
problem solving totally on the client. Option B places the client’s feelings on hold. Option 1 immediately blocks
communication.
Reference: Fortinash. Psychiatric mental health nursing 3rd edition. Pages. 546-547
: Stuart and Laraia. Principles and practice of psychiatric nursing 8th edition. Pages 30-31)
99. Nurse Isabelle has been working with a victim of rape in a clinic setting for the past 4 weeks. Which of the
following is unrealistic as a short term initial goal?
a. Physical wounds will heal
b. The client will participate in the treatment plan
c. The client will verbalize feelings about the event
d. The client will resolve feelings of fear and anxiety related to the rape trauma
ANSWER: D
Short-term goals include the beginning stages of dealing with the rape trauma. Clients will be expected initially to
keep appointments, participate in care, begin to explore feelings, and begin to heal any physical wounds that
were inflicted at the time of the rape.
Reference: Varcarolis, E. Foundations of psychiatric mental health nursing. 5th edition. Page 533-534
100. A mother tells the nurse during an admission interview that her 2-year-old, who has numerous bruises, has
fallen down stairs frequently. The mother is able to provide few details. The nurse evaluates this as:
a. Possible child abuse.
c. Normal behavior for a 2-year-old.
b. Knowledge deficit pertaining to home safety.
d. Possible attention deficit disorder.
Answer: A
Rationale: The numerous bruises and the mother’s vague explanations of the injuries indicate possible child
abuse. Home safety is important but not as important as the child’s safety (option B). Falling down stairs
frequently is not normal behavior for a 2-year-old (option C), nor is it a symptom of attention deficit disorder
(option D).
MENTAL HEALTH AND PSYCHIATRIC NURSING
THERAPEUTIC MODALITIES
SITUATION: Petra is a middle aged woman who has gone through a very bad divorce. She is extremely
depressed, locks herself in her room, and cannot go to work. She tried to kill herself by cutting her wrists, but
unsuccessful because the cuts are not deep enough. She ends up at a hospital emergency room and was
transferred to the psychiatric ward. Her sister has a conference with the doctor and agrees Petra should have
ECT. Her sister is amazed that when she goes to visit Petra she cannot remember the names of her children. She
has even walked out into the hall naked. Her sister is worried that she made the wrong call. As it happens,
several days after the ECT Petra started to smile and talk with her sister about how well things are going. She
doesn’t remember why she had the problem in the first place. Petra’s sister wonders if her sister’s memory is
going to be permanently affected.
1. Petra’s asks the nurse about the preparations for ECT. Which of the following statements if made by the nurse
would indicate understanding about ECT preparations?
a. “Preparation is similar to that of undergoing minor surgery”
c. “A signed consent form is all you need”
b. “There are no special preparations for ECT”
d. “It depends on the case of the patient”
ANSWER: A
Preparation of client for ECT is similar to preparation for any minor surgery. The patient must have a pretreatment evaluation,
including physical examination, laboratory work and baseline memory abilities. A consent
form must be signed. Because ECT is given as a treatment of last resort. The client receives nothing by mouth
after midnight, removes any fingernail polish, and voids just before the procedure. An intravenous line is started
for the administration of medication.
Reference: Videbeck. Psychiatric Nursing. 3rd edition. Page 316
: Norman Keltner. Psychiatric Nursing. Page 572-573
2. When a patient does not improve with antidepressant medication, the physician orders electroconvulsive
therapy. ECT’s exact mechanism of action is:
a. Similar to that of antidepressant drugs
b. It increases the production of chemicals in the brain
c. It corrects the chemical imbalance in the brain by electric current
d. Unknown
ANSWER: D
Although ECT produces rapid movement in depressive symptoms, its exact mechanism of antidepressant action
remains unclear.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 129
3. What is the most common side effect of ECT?
a. Dizziness
b. Nausea and vomiting
c. Confusion and memory loss
d. GI disturbances
ANSWER: C
Side effects of ECT include headache, nausea, muscle pain and , mildly confused and disoriented. The symptoms
are just like those anyone who has had a grand mal seizure. In addition client will have some short-term
memory impairment. After treatment, the client may eat a soon as he/she is hungry and usually sleeps for a
period. Headaches are treated symptomatically.
Reference: Videbeck. Psychiatric Nursing. 3rd edition. Page 317
4. Which of the following medications is given before ECT to prevent aspiration?
a. Atropine
b. Anectine
c. Brevital
d. Ritalin
ANSWER: A
Atropine is given 1 hour before the treatment or intravenously immediately preceding treatment. Atropine
reduces secretion and subsequent risk of aspiration and counteracts the ECT-induced vagal stimulation. Anectine
, a muscle relaxant, prevents the musculoskeletal complications from induced convulsions. Brevital, a barbiturate,
induces a light coma preceding delivery of ECT. Ritalin, a CNS stimulant, is used for patient with ADHD
Reference: Norman Keltner. Psychiatric Nursing. Page 572-573
5. Which of the following complaints should the nurse addresses initially after ECT?
a. “My head hurts”
b. “I can’t breathe”
c. “Where am I?”
d. “I want to eat”
ANSWER: B
Nursing responsibilities after ECT includes: Orienting the client to time, place and person and monitoring the
client for problems in respiration because succinylcholine (Anectine) causes respiratory depression. Oxygen is
administered immediately before and after treatment until the patient can breathe unassisted.
Reference: Norman Keltner. Psychiatric Nursing. Page 572-573
6. Which of the following clients would most likely be found to be the best candidate for ECT?
a. One who has rapid cycling bipolar disorder
b. A client who fails to respond to MAOIs and tricyclic antidepressants
c. A client who has not responded to monoamine oxydase inhibitors (MAOIs)
d. A severely malnourished depressed client at risk for medical complications
ANSWER: D
In 1997, Welch delineated several groups as good candidates for ECT. One of these groups was severely
malnourished depressed clients at risk for medical complications. Clients who did not respond to traditional
antidepressant regimens are also candidates, but clients who fail to respond to MAOIs and tricyclics still have
other antidepressants to try and do not have as urgent a need as the severely malnourished depressed client.
Reference:Antai-Otong. Psychiatric Nursing: Biologic and Behavioral Concept 2nd edition
7. The efficacy of ECT is linked to the production of which of the following kinds of seizure?
a. Absence
b. Petit mal
c. Grand mal
d. Jacksonian
ANSWER: C
The efficacy of ECT is linked with the production of grand mal seizures. Animal research indicates that the
seizures elicited by ECT create alterations in neurochemical, neuroendocrine, and neurophysiological processes
that are similar to those produced by antidepressants.
Reference:Antai-Otong. Psychiatric Nursing: Biologic and Behavioral Concept 2nd edition

8. A severely depressed client who is pregnant and at risk of malnutrition tells you that she is going to be
scheduled for ECT. From your understanding of ECT today, you realize that this client:
a. Cannot have ECT in the first or second trimester
b. Will need to improve nutritionally before getting ECT
c. Will not be able to have ECT until after the baby is born and lactation has ceased
d. Could possibly have ECT if the benefits outweigh the potential dangers of the procedure
ANSWER: D
You realize that even though the client is pregnant and at risk for malnutrition and suicide, she may still be a
candidate for ECT. The client would have to be monitored during and after the treatment. The usefulness of
administering ECT to a pregnant client must outweigh the potential dangers of this procedure before it can be
implemented.
Reference: Antai-Otong. Psychiatric Nursing: Biologic and Behavioral Concept 2nd edition
9. Nurse Allan recognizes that the focus of milieu therapy is to:
a. Manipulate the environment to bring about positive changes in behavior
b. Allow the client’s freedom to determine whether or not they will be involved in activities
c. Role plays life events to meet individual needs
d. Use natural remedies rather than drugs to control behavior
ANSWER: A
Environmental (MILIEU) therapy aims at having everything in the client’s surrounding area toward helping the
client.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 175
10. During discussion, Nurse Hannah encourages the client to voice out their ideas or opinions while respecting
the rights of others. Nurse Hannah is using what type of therapeutic modality?
a. Assertiveness training
b. Implosive therapy
c. Cognitive behavior therapy
d. Limit setting
ANSWER: A
During assertiveness training, clients are taught how to relate appropriately to others using frank, honest and
direct expressions, whether these are positive or negative in nature. Teaches the client to ask for what is wanted,
to take position on various issues and to initiate specific action to obtain what one wants while respecting the
rights of others. Option B: Implosive therapy or Flooding is the opposite of systematic desensitization. Person are
exposed to intense form of anxiety producers, either in imagination or in real life. Option C: CBT, uses
confrontation as a means of helping clients restructure irrational beliefs and behavior. Option D: Limit setting is
giving advanced warning of the limit and the consequences that will follow if the client does not adhere o the
limit.
Reference: Shives. Psychiatric-Mental Health Nursing. 7th edition Page 164
SITUATION: Electroconvulsive therapy (ECT) is a treatment for severe mental illness in which a brief application
of electric stimulus is used to produce a generalized seizure. As often occurs with new therapies, ECT was used
for a variety of disorders, frequently in high doses and for long periods. Many of these efforts proved ineffective,
and some even harmful.
11. A hospitalized client is being considered for ECT. The client appears calm, but the family is anxious. The
client’s mother begins to cry and states, “My son’s brain will be fried, how can the doctor do this to him?” What is
the nurse’s best response?
a. “It sounds as though you need to speak to the psychiatrist”
b. “Your son has decided to have this treatment, you should be supportive of him”
c. “Perhaps you’d like to see the ECT area and meet the staff”
d. “It sounds as though you have some concerns about the procedure, why don’t’ we sit down and discuss any
concerns you may have”
ANSWER: D
In option D, the nurse encourages the client and family to verbalize fears and concerns. Other options avoid
dealing with concerns and are non-therapeutic.
Reference: Varcarolis. Foundations of Psychiatric Nursing. 3rd edition. Page 579
12. A neuromuscular blocking agent is administered to a client before ECT therapy. The nurse should carefully
observe the client for which of the following?
a. Respiratory difficulties
b. Nausea and vomiting
c. Dizziness
d. Seizures
Answer: A
Neuromuscular Blocker, such as SUCCINYLCHOLINE (Anectine) produces respiratory depression because it
inhibits contractions of respiratory muscles.
Reference: Videbeck, Sheila L. Psychiatric Mental Health Nursing, 2nd edition, Page 340
13. Which of the following interventions is the highest priority during the post ECT care?
a. Observe for confusion
c. Reorient to time, place and person
b. Monitor respiratory status
d. Document the client’s response to the treatment
Answer: B
A side effect of ECT which is life threatening is respiratory arrest. Options A and C: Confusion and disorientation
are side effects of ECT but these are not the highest priority, neuromuscular Blocker, such as SUCCINYLCHOLINE
(Anectine) produces respiratory depression because it inhibits contractions of respiratory muscles.
Reference: Videbeck, Sheila L. Psychiatric Mental Health Nursing, 2nd edition, Page 340
SITUATION. The nurse is preparing a client who is about to undergo electroconvulsive therapy.
14. The nurse administers atropine sulfate prior to ECT. Which assessment indicates that the medication is
effective?
a. The client's heart rate is 48 beats/minute
c. The client appears calm and relaxed
b. The client states that his mouth is dry
d. The client falls asleep.
ANSWER: B
Atropine sulfate is administered approximately 30 minutes before electroconvulsive therapy to reduce oral
secretions; therefore, the client's mouth would feel dry.
Option A - Atropine also blocks the vagal stimulation of the heart, causing a rise in heart rate (much higher than
48 beats/minute).
Option C and D - Atropine sulfate isn't given to make the client feel calm and relaxed nor does it induce sleep.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 316
15. The nurse is documenting a care plan for the client post -ECT. Which intervention should the nurse include?
a. Monitoring the client's vital signs every hour for 4 hours
c. Encouraging early ambulation
b. Placing the client in Trendelenburg's position
d. Reorienting the client to time and place
ANSWER: D
Confusion and temporary memory loss are the most common adverse effects of electroconvulsive therapy. The
nurse should continually reorient the client to time and place as he wakes up from the procedure.
Option A - Following electroconvulsive therapy, the nurse should monitor the client's vital signs every 15 minutes
for the 1st hour.
Option B - The nurse should position the client on his side after the procedure to reduce the risk of aspiration.
Option C - The client should remain on bed rest until he's fully awake and oriented.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 316
SITUATION: Light therapy and medications appear to work best in combination, suggesting it would be
advantageous to offer depressed patients speedy relief with light therapy while also starting them on medications
that have more extensively verified efficacy. Combined treatment of depression can lower costs because faster
improvement means less disability and morbidity.
16. When teaching stress management to clients, the nurse will most likely advocate which of the following as a
method of coping with stressful life events?
a. Avoidance of stress is an important goal for living
c. Most people have no control over their level of stress
b. Control over one’s response to stress is possible
d. Significant others are important to provide care and concern
ANSWER: B
When learning to manage stress, clients find it helpful to believe that they have the ability to control the response
to it. It is impossible to avoid stress, which is a normal life experience. Stress can be positive and growth
enhancing as well as harmful. The belief that one has some control is the significant factor to minimizing stress.
Although significant others are important, the client’s ability to help himself to cope is essential.
Reference: Ann Isaac. Mental health and Psychiatric Nursing. Page 43-49
17. A client scheduled to receive phototherapy asks the nurse what phototherapy is. The nurse should respond
with which of the following statements?
a. “It is a camera that takes pictures of your brain to see why you are becoming depressed”
b. “It is a bright white light that is used to help treat depression in winter months”
c. “It assists in decreasing stress and will help you function better at work in the winter months”
d. “It is used to treat depression that is resistant to ECT”
ANSWER: B
Phototherapy is a bright white light that is used to treat seasonal affective depression in the winter months. The
light approximately 2500 lux can be used from 30 minutes to 2 hours each day during winter months. It does
not decrease stress and most likely would be used prior or after ECT treatment.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 130
18. The client asks Nurse Sergio how long phototherapy should be used each day. Which of the following is the
appropriate response of Nurse Sergio?
a. “If you get a headache, then you have sat in front of light for too long”
b. “Each individual is different. Sit in front of the light just enough so that you do not get a headache”
c. “You may sit in front of the light as long as you want”
d. “Sit in front of the light while reading, preferably in the evening”
ANSWER: B
If a client sits in front of the phototherapy light for too long, the client will develop a headache. The length of
time is different for each individual. Some individual may experience a headache within 30 minutes. Sitting in
front of the light while reading or comfortable are statements of when , not how long, the client should use the
phototherapy each day. During the first one or two treatments, the client may get a headache because the period
of treatment has not yet been established nor does the client know yet what reaction there will be to the
treatment. And phototherapy should be done upon arising and is most effective before 8 am.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 130
SITUATION: Psychopharmacology is the second component of the psychotherapeutic treatment (Self,
Psychopharmacology, Milieu). Because the nurse provides 24 hour care, she is responsible for assessing drug side
effects, evaluating desired effects and applying preventive care to reduce potential problems.
19. Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client
for which of the following conditions?
a. Hyperpyrexia, slow pulse, and weight gain
c. Hypotension, weight gain, and listlessness
b. Tachycardia, weight loss, and mood swings
d. Increased appetite, slowing of sensorium, and arrhythmias
ANSWER: B
Stimulants produce mood swings, anorexia and weight loss, and tachycardia. The other symptoms indicate CNS
depression.
Reference: Amy Karch. Focus on Nursing Pharmacology. 3rd edition. Page 334
20. Additive central nervous system (CNS) depression can occur when combining a sedative-hypnotic with which
drug?
a. Methylphenidate (Ritalin)
b. Cocaine
c. Amitriptyline (Elavil)
d. Amphetamine (Adderall)
ANSWER: C
Additive effects occur with concomitant use of CNS depressants, antihistamines, antidepressants, and
antipsychotics. Elavil is an antidepressant and the only correct answer. All the other drugs are classified as
stimulants.
Reference: Norman Keltner. Psychiatric Nursing. Page 243
21. During health teaching session, which instruction should the nurse give to a client taking alprazolam (Xanax)?
a. "Stop medication if you experience nausea."
b. "Call the doctor if you experience urinary retention."
c. "Apply sunscreen to prevent photosensitivity."
d. "Inform the physician if you become pregnant or intend to do so."
ANSWER: D
Because alprazolam is contraindicated during pregnancy because it crosses the placenta and it will increase the
risk of birth defect. The client should be instructed to inform the physician if she becomes pregnant. Nausea,
urine retention, and photosensitivity are adverse reactions that may occur, but aren't contraindications.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 124
22. Benztropine (Cogentin) is used to treat the pseudoparkinsonism induced by antipsychotics. The mechanism of
action of this drug is to:
a. Decrease the anxiety causing muscle rigidity.
b. Block the cholinergic activity in the central nervous system (CNS).
c. Increase the level of acetylcholine in the CNS.
d. Increase norepinephrine in the CNS.
ANSWER: B
Option 2 is the action of benztropine. Anxiety doesn't cause extrapyramidal effects. Overactivity of acetylcholine
and lower levels of dopamine is the cause of extrapyramidal effects, the treatment is the administration of a
medication that inhibit acetylcholine and thereby restore balance of neurotransmitters. Benztropine doesn't
increase norepinephrine in the CNS.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 112-113
23. Which information is most important for the nurse to include in a teaching plan for a schizophrenic client
taking clozapine (Clozaril)?
a. Monthly blood tests will be necessary.
b. Report a sore throat or fever to the physician immediately.
c. Hypertension is problem and must be monitored.
d. Immediately stop medication when feeling well.
ANSWER: B
A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening
complication of clozapine therapy. Because of the risk of agranulocytosis, white blood cell (WBC) counts are
necessary weekly, not monthly. If the WBC count drops below 3,000/µl, the medication must be stopped.
Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness
from orthostatic hypotension. The medication should be continued, even when symptoms have been controlled. If
the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of
a physician.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 112
24. Which of the following is one of the advantages of the newest antipsychotic medication risperidone
(Risperdal)?
a. The absence of anticholinergic effects
c. Photosensitivity and sedation
b. A lower incidence of extrapyramidal effects
d. No incidence of neuroleptic malignant syndrome
ANSWER: B
Risperdal has a lower incidence of extrapyramidal effects than do the typical antipsychotics. Risperdal does
produce anticholinergic effects, and neuroleptic malignant syndrome although rare can occur. Photosensitivity
isn't an advantage.
Reference: Norman Keltner. Psychiatric Nursing. Page 228
25. The physician orders lithium carbonate (Lithonate) for a client who's in the manic phase of bipolar disorder.
During lithium therapy, the nurse should watch for which adverse reactions?
a. Weakness and urine retention
c. Constipation, lethargy, and ataxia
b. Anxiety, restlessness, and sleep disturbance
d. Nausea, diarrhea, tremor, and lethargy
ANSWER: D
The most common adverse effects of lithium are nausea, diarrhea, tremor, and lethargy. Lithium doesn't cause
weakness, urine retention, anxiety, restlessness, sleep disturbance, constipation, or ataxia.
Reference: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 375
26. The physician has prescribed sertraline (Zoloft) 50 mg daily for a client with depression. Which finding should
be reported to the physician?
a. The client takes cimetidine (Tagamet) for acid reflux.
c. The client takes the medication once a day at bedtime.
b. The client takes the medication with meals.
d. The client takes naproxen (Naprosyn) for arthritis.
ANSWER: A
Tagamet decreases the clearance time of Zoloft, thereby increasing the likelihood of toxicity. The medication can
be taken with meals or once a day at bedtime; therefore, Answers B and C are incorrect. The medication can be
taken with naproxen; therefore, Answer D is incorrect.
Reference: Videbeck, Sheila L. Psychiatric Mental Health Nursing, 2nd edition, Page. 337
SITUATION: Group interventions can have powerful treatment effects on patients who are trying to develop selfunderstanding,
conquer unwanted thoughts and feelings, and change behaviors. They are efficient because
several patients can receive treatment at once.
27. The nurse provides referral for a client who describes a 20 year history of alcohol abuse to alcoholic
anonymous. The primary function of this group is to:
a. Encourage the use of a 12 step program
c. Provide fellowship among members
b. Help members maintain sobriety
d. Teach positive coping mechanisms
ANSWER: B
The primary purpose of Alcoholic Anonymous (AA) is to help members achieve and maintain sobriety. Although
each of the remaining answer choices may be an outcome of attendance at alcoholics anonymous, the primary
purpose is directed toward sobriety of members
Reference: Norman Keltner. Psychiatric Nursing. Page 529
28. The nurse assesses that a number of parents in a child care clinic have misconceptions about child
development in relationship to discipline. In which type of group setting can the nurse address the issue?
a. Activity group
b. Education group
c. Self help group
d. Support group
ANSWER: B
An education group is best designed to impart information on topics of common interests to a group such as the
child development information needed by the parents in this situation. Activity groups encourage nonverbal
expressions of feelings and would be inappropriate for this situation. Self-help groups are member-run rather
than planned by mental health team members. Support groups are designed to provide acceptance and empathy
for members, not to impart identical knowledge
Reference: Norman Keltner. Psychiatric Nursing. Page 144-146
: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 198
: Ann Isaac. Mental health and Psychiatric Nursing. Page 239
29. The community nurse is working with a support group and notes a high rate of absenteeism and minimal
participation by members. Which leadership style is the nurse most likely using in this situation?
a. Authoritarian
b. Democratic
c. Laissez-faire
d. Facilitator
ANSWER: A
When the leader style is authoritarian, the group may demonstrate passive-aggressive behavior, such as
absenteeism and minimal participation. Democratic leadership leads to loyalty and productive group work.
Laissez-faire leadership may contribute to disorganized group functioning and apathy. Option D does not describe
a leadership style
Reference: Ann Isaac. Mental health and Psychiatric Nursing. Page 237
SITUATION: The issues of alternative medicine demand our attention as health care professionals. Regardless of
whether the health care professionals endorse or recommend the use of these alternative therapies.
30. This herb is used as a treatment for mild to moderate depression:
a. St. John’s Wort
b. Gingko biloba
c. Angelica
d. Chamomile
ANSWER: A
St john’s Wort is used as a treatment for mild to moderate depression. Gingko Biloba has demonstrated
improvement in ceoncentration, memory, and mood in patients with dementis. Angelica cause significant muscle
relaxation without changes in level of consciousness. Chamomile promote relaxation and sleep and decreases
anxiety.
Reference: Norman Keltner. Psychiatric Nursing. Page 584-587
31. The nurse would instruct a client interested in taking the herb Gingko Biloba to improve cognitive function
that it cannot be used with which of the following medications?
a. Anticoagulants
b. Antidepressant
c. Antihypertensive
d. Antidiarrheal
ANSWER: A
Gingko biloba appears to be inhibiting the platelet-activating factor. Anticoagulant is contraindicated to person
using the gingko biloba. Other options: incorrect
Reference: Shives. Psychiatric-Mental Health Nursing. 7th edition Pages 270
32. The nurse who is planning care for a female client complaining of severe pain from chronic rheumatoid
arthritis incorporates the use of guided imagery and relaxation therapy. The nurse understands that these
techniques achieve pain relief by which mechanisms?
a. Allows client to detach herself from the pain
c. Stimulates brain to release endorphins
b. Promotes concentration on sensations other than pain
d. Corrects the imbalance of vital energy
ANSWER: B
Relaxation therapy, guided imagery, biofeedback and meditation uses the client’s ability to concentrate on focal
points thus reducing painful stimuli. Option A: Hypnosis , an excellent way to mobilize a client’s resources to alter
physical sensations such as pain, allows the client to concentrate on competing sensations or simply to detach
themselves. Option C: Aromatherapy stimulates the brain to release endorphins for pain control. Option D:
Acupressure , based on the concept of chi, the essential life force, this Chinese practice uses finger pressure at
the same points that are used in acupuncture to balance chi and achieve health.
Reference: Shives. Psychiatric-Mental Health Nursing. 7th edition Pages 262-268
33. What is the expected outcome when working with a client who has experienced a crisis?
a. Stabilization of moods with medications and return to previous levels of functioning
b. Recovery from the crisis and return to pre crisis levels of functioning
c. Recovery from the crisis with intense out client therapy
d. Recovery from the crisis with total adjustment at pre crisis events
ANSWER: D
34. An actively psychotic client is being assessed by the nurse for a participation in a milieu group. Which is the
most
appropriate group for this client?
a. A highly structured task oriented group
c. A group is not appropriate
b. An activity group
d. A movement therapy group, after a short period of isolation
ANSWER: C
35. The role of the nurse in environmental therapy includes:
a. Coordinating team activities, maintaining the environment 24 hrs. a day
b. Referring others to work with families, observing in groups
c. Coordinating medical care, selecting programs
d. Observing community meetings leading groups
ANSWER: A
36. The activity therapy the nurse would select to promote reminiscing in a group with age over 70 is:
a. Poetry
b. Art
c. Movement
d. Music
ANSWER: D
37. The registered nurse is discussing with a student the guidelines for the use of restraints. Which of the
statements by the students indicates a need for clarification?
a. An adequate number of staff are needed before restraints are attempted.
b. Being restrained may help the client gain physical control
c. A physician’s order is required initially, followed by frequent renewal
d. The use of restraints requires the supervision of a licensed and certified professional
ANSWER: D
38. A client seeks counseling from the nurse for marital conflict that includes a history of physical abuse. What
would be
the initial intervention in this client’s plan of care?
a. Assist the client in identifying aspects of the client’s life that are under the control of the client
b. Facilitate the client’s desire to gain knowledge of the democratic family process
c. Discuss issues of the use of stereotypic gender role behavior and the effect of violence in the family
d. Explain theories of family violence so the client understands patterns in the marital conflict
ANSWER: B
39. A client is to receive his first electro convulsive treatment (ECT). He states, “I’m afraid because my roommate
told me I’ll forget everything and my memory will never return.” What is the best response?
a. Don’t worry about it. You will get your memory back.”
b. You may not experience memory loss, but you still need ECT to get better.”
c. It may be best if you can’t remember certain things.”
d. There is memory loss, but it will return over a 2 3 week period
ANSWER: D
40. A therapist is leading in a client group. Which is most important to the development of the group process?
a. Planning
b. Goal setting
c. Problem solving
d. Reality orientation
ANSWER: B
41. Therapeutic treatment of a female client with ritualistic behavior should be directed
to:
a. Redirect her energy into activities to help others
b. Learn that her behavior is not serving a realistic purpose
c. Forget her fears by administering antianxiety medications
d. Understand her behavior is caused by unconscious impulses that the fears
ANSWER: D

toward helping her

42. A client is participating in a crafty therapy session when suddenly he begins to shout at another client, “Stop
watching me. I know what you’re up to. I’ll get you…” What will be the best immediate action for the nurse to
take?
a. Disband the group immediately
c. Tell the client that no one is watching her
b. Instruct the client to follow the nurse to her room
d. Ask the other clients to stop looking at this person
ANSWER: B
SITUATION: Inpatient treatment is often the last, rather than the first, mode of treatment for mental illness.
Current treatment reflects the belief that it is more beneficial and certainly more cost-effective for clients to
remain in the community and receive outpatient treatment whenever possible.
43. A client tells you that his nurse psychotherapist uses eclecticism. You realize that the therapist is using which
of the following treatment approaches?
a. Two or more theories which show promise to effectively meet the client's needs
b. Gestalt approaches developed by Carl Rogers along with solution-oriented work
c. Energy force field theories developed by Martha Rogers who was a nurse theorist
d. Combination psychotherapy and electric shock therapy while working with a psychiatrist
ANSWER: A
The term eclecticism in psychotherapy implies that the therapist uses two or more theories to meet a client's
needs and develop effective treatment. An eclectic approach increases the likelihood that psychotherapy will be
successful and provides the client an assortment of interventions.
Reference:Antai-Otong. Psychiatric Nursing: Biologic and Behavioral Concept 2nd edition
44. One of your assigned clients who is seeing a psychoanalyst twice a week describes the psychoanalyst using a
technique called free association. You realize that free association involves the client’s:
a. saying the first thing that comes to mind in response to words or phrases
b. determining the agenda for the therapy and working on self-determined goals
c. speaking nonstop after receiving sodium amytal to reduce unconscious inhibitions
d. talking about whatever comes to mind as the therapist listens without taking notes
ANSWER: A
In free association, the therapist says a word or phrase and the client responds with the first thing that comes to
mind. By identifying the first thing that comes to mind, conscious screening and censorship do not occur. The
responsibility of the therapist is to search for patterns in the client’s responses. Material that is verbalized and
material that is unconsciously avoided is examined. Areas of conflict which are not verbalized may indicate
resistance on the client’s part.
Reference:Antai-Otong. Psychiatric Nursing: Biologic and Behavioral Concept 2nd edition
45. A client begins reacting to his psychoanalyst in much the same way that he reacted to his father in the past.
This behavior on the part of the client represents:
a. Transference
b. A lasting habit
c. A control issue
d. Countertransference
ANSWER: A
Transference refers to the unconscious displacement, or reenactment, of feelings and attitudes from the client to
the psychotherapist. It is a concept reflective of a psychoanalysis approach. Transference can be viewed as either
negative or positive. In positive transference, the client displaces feelings of warmth, esteem, or love for
someone else onto the therapist. In negative transference, the client reacts to the therapist with hate, anger, or
rage that is felt toward some other person.
Reference:Antai-Otong. Psychiatric Nursing: Biologic and Behavioral Concept 2nd edition
46. The nurse psychotherapist has chosen to use behavioral therapy on a client who has presented with a fear of
flying. The nurse has most likely selected behavioral therapy based on a belief that this client's behavior:
a. Is part of a symptom complex
c. Can be controlled by a reward system
b. Was learned and can be unlearned
d. Will respond to a type of brief therapy
ANSWER: B
Behavioral therapy is based on the assumption that complex human behaviors or responses are learned and,
therefore, may be unlearned. Several techniques can be used including systemic desensitization, flooding,
participant modeling, aversion therapy, positive reinforcement, assertiveness and social skills training.
Additionally, psychotropic drugs may be used.
Reference:Antai-Otong. Psychiatric Nursing: Biologic and Behavioral Concept 2nd edition
47. After a group session, a member of the group shares with the leader that she felt important for the first time
in a long time and enjoyed sharing her experiences with another member who had said this gave her some new
ideas for making her life better. This client is describing a benefit from the group that best matches which of the
following therapeutic factors of group as identified by Yalom?
a. Altruism
b. Universality
c. Group cohesiveness
d. Imparting of information
ANSWER: A
Yalom identified eleven therapeutic factors for group therapy. The client is describing what Yalom called
“altruism.” Altruism is the giving of each group member to another within the group. This process is therapeutic
and increases the giver's self-esteem.
Reference:Antai-Otong. Psychiatric Nursing: Biologic and Behavioral Concept 2nd edition
48. The nurse leader of a psychoanalytically oriented group session is the recipient of the anger of one of the
group members. This anger seems unrelated to anything the group leader or members have said or done. The
best course of action for the nurse leader is most probably going to be which of the following actions?
a. Ignore the angry outburst
c. Inform the angry member of a need to discuss this after group
b. Examine the anger in the group
d. Tell the angry member that this behavior is unacceptable in group
ANSWER: B
The nurse leader will most likely examine the anger in the group. The analysis of the anger will reveal that the
nurse is experiencing the transference of the client who has shifted feelings about another person onto the
leader. Transference can be successfully examined in the group setting and used to assist clients to gain insight
into feelings and behaviors.
Reference:Antai-Otong. Psychiatric Nursing: Biologic and Behavioral Concept 2nd edition
49. The nurse assesses that a number of parents in a child care clinic have misconceptions about child
development in relationship to discipline. In which type of group setting can the nurse address the issue?
a. Activity group
b. Education group
c. Self help group
d. Support group
ANSWER: B
An education group is best designed to impart information on topics of common interests to a group such as the
child development information needed by the parents in this situation. Activity groups encourage nonverbal
expressions of feelings and would be inappropriate for this situation. Self-help groups are member-run rather
than planned by mental health team members. Support groups are designed to provide acceptance and empathy
for members, not to impart identical knowledge
Reference: Norman Keltner. Psychiatric Nursing. Page 144-146
: Mary Ann Boyd. Psychiatric Nursing. 4th edition. Page 198
: Ann Isaac. Mental health and Psychiatric Nursing. Page 239
50. The community nurse is working with a support group and notes a high rate of absenteeism and minimal
participation by members. Which leadership style is the nurse most likely using in this situation?
a. Authoritarian
b. Democratic
c. Laissez-faire
d. Facilitator
ANSWER: A
When the leader style is authoritarian, the group may demonstrate passive-aggressive behavior, such as
absenteeism and minimal participation. Democratic leadership leads to loyalty and productive group work.
Laissez-faire leadership may contribute to disorganized group functioning and apathy. Option D does not describe
a leadership style
Reference: Ann Isaac. Mental health and Psychiatric Nursing. Page 237
51. According to the principles of family psychotherapy, the major task of the consolidation stage of family
development is:
a. Last child leaves home
c. Renewal of couple’s relationship
b. Identity and separation
d. Conflict resolution and adapting to conflict
ANSWER: D
The major task for a family in the consolidation stage of family development is conflict resolution. These conflicts
frequently involve parent-child conflicts. Other conflicts may occur between the couple.
Reference:Antai-Otong. Psychiatric Nursing: Biologic and Behavioral Concept 2nd edition
52. Which of the following represents the family’s ability to use adaptive coping when confronted by stressors?
a. Scapegoating
b. Triangulation
c. Relationship resilience
d. Establishing boundaries
ANSWER: C
Relationship resilience refers to the family’s ability to mobilize resources and confront psychosocial and biological
stress effectively using adaptive coping responses to foster a sense of collaboration, competence, and confidence
in its members. Healthy families are capable of withstanding and rebounding from crisis and distress because of
their rational resilience.
Reference:Antai-Otong. Psychiatric Nursing: Biologic and Behavioral Concept 2nd edition
53. Which of the following somatic therapies is the least acceptable still in use and used only as a last resort
when clients fail to respond to other treatments?
a. ECT
b. Psychosurgery
c. Cold wet sheet packs
d. Insulin shock therapy
ANSWER: B
Only two of the choices are still in use, ECT and psychosurgery. While ECT is not a front line, first choice of
therapy, psychosurgery would be the least acceptable therapy still in use and is used only as a last resort when
all other treatments have failed. Originally, psychosurgery involved prefrontal lobotomy. Currently, alterations of
fronto-limbic pathways that alter emotional disturbances, such as chronic debilitating mental disorders that fail to
respond to traditional treatment and chronic intractable depression are the chief reasons for psychosurgery.
Reference:Antai-Otong. Psychiatric Nursing: Biologic and Behavioral Concept 2nd edition
SITUATION: The field of mental health often seems a little unfamiliar or mysterious, making it hard to imagine
what the experience will be like or what nurses do in this area.
54. Mental health and mental illness are difficult to define precisely. Mental health is defined as:
a. The ability to distinguish what is real from what is not.
b. A state of well-being where a person can realize his own abilities can cope with normal stresses of life and
work productively.
c. Is the promotion of mental health, prevention of mental disorders, nursing care of patients during illness and
rehabilitation
d. Absence of mental illness
ANSWER: B
A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work
productively. Mental health is a state of emotional and psychosocial well being. A mentally healthy individual is
self aware and self directive, has the ability to solve problems, can cope with crisis without assistance beyond the
support of family and friends fulfill the capacity to love and work and sets goals and realistic limits. Option A: This
describes the ego function reality testing. Option C: This is the definition of Mental Health and Psychiatric
Nursing. Option D: Mental health is not just the absence of mental illness.
55. In group therapy, a client angrily speaks up and responds to a peer, "You're always whining and I'm getting
tired of li5stening to you! Here is the world's smallest violin playing for you." Which role is the client playing?
a. Blocker
b. Monopolizer
c. Recognition seeker
d. Aggressor
ANSWER: D
The aggressor is negative and hostile and uses sarcasm to degrade others. The role of the blocker is to resist
group efforts. The monopolizer controls the group by dominating conversations. The recognition seeker talks
about accomplishments to gain attention.
56. What is the nurse's most important role in caring for a client with a mental health disorder?
a. To give advice to psychologically impaired client
c. Setting limits to client
b. To know how to solve the client's problems
d. To build trust and rapport
ANSWER: D
It's extremely important that the nurse establish trust and rapport. The nurse shouldn't offer advice. Instead, she
should help the client develop the coping mechanisms necessary to solve his own problems. Setting limits is also
important but not as important as developing trust and rapport.
57. Nurse Hannah is using drawing, puppetry, and other forms of play therapy while treating a terminally ill,
school-age child. The purpose of these techniques is to help the child:
a. Internalize his feelings about death and dying
c. Express feelings that he can't communicate
b. Accept responsibility for his situation
d. Have fun while at the hospital
ANSWER: C
Children may not have the verbal and cognitive skills to express what they feel and may benefit from alternative
modes of expression. It's important for the child to find a way to express internalized feelings. The child must
also know that he is not to blame for this situation. In the process of participating in play therapy, the child can
also have fun, but that isn't the main goal of therapy.
58. What is the critical difference between the nurse-client relationship and a social relationship?
a. The nurse-client relationship focuses on the client's needs.
b. The nurse-client relationship is based on an initial client dependency.
c. The nurse-client relationship is reciprocal.
d. The nurse-client relationship requires that each phase is fully developed.
ANSWER: A
The phases of the relationship are important; however, there are many nurse-client relationships that may not
have fully developed phases, for example, a shortened hospital stay may limit how developed the phases may be.
Reference: Fontaine. Mental Health Nursing 5th edition
59. In which phase of the Peplau's description of the nurse-client relationship would you expect a therapeutic
alliance? a. Pre-Introductory Phase
b. Introductory Phase
c. Working phase
d. Termination
ANSWER: C
The therapeutic alliance, the conscious process of working together toward mutually established goals, occurs in
this phase.
Reference: Fontaine. Mental Health Nursing 5th edition
60. Which of the following is the most accurate and helpful statement about genetics and mental health?
a. Individual genes are the focus when considering mental health and illness.
b. Genes are considered separately from environmental factors.
c. Genes only tell us about susceptibility.
d. Genes are not critical to our understanding of mental health or mental illness.
ANSWER: C
This is the best and most accurate statement. Genes do not convey disease per se but tell us an individual may
be more susceptible to illness.
Reference: Fontaine. Mental Health Nursing 5th edition
61. In observing clients, if you ask if the client is dangerous to himself or others what type of observation are you
using?
a. Cognitive
b. Physiological
c. Behavioral
d. Sociocultural
ANSWER: C
In physiological observation you would focus on the client's motor behavior, nutritional status, sleep pattern, and
physical problems.
Reference: Fontaine. Mental Health Nursing 5th edition
62. According to Erikson's theory, in which stage of development would you expect a child to direct his/her
energy toward achieving, such as in creative activities and in learning?
a. Sensory
b. Adolescent
c. Muscular
d. Latency
ANSWER: D
In this stage children are learning to see the relationship between perseverance and the pleasure of a job
completed" The important event at this stage is attendance at school. As a student, the children have a need to
be productive and do work on their own. They are both physically and mentally ready for it. Interaction with
peers at school also plays an imperative role of child development in this stage. The child for the first time has a
wide variety of events to deal with, including academics, group activities, and friends. Difficulty with any of these
leads to a sense of inferiority
Reference: Fontaine. Mental Health Nursing 5th edition
63. Kiko's communication is very difficult to follow. One staff member says, "I just can't listen for long. He gives
all this detail. I know eventually he will make his point, but who can wait!" Another staff member comments that
Kiko also makes up new words, which makes it even more difficult to communicate with him. Based on this data,
what type of thought does Kiko exhibit?
a. Blocking and loose associations
c. Circumstantiality and neologism
b. Confabulation and tangential thoughts
d. Derailment and flight of ideas
ANSWER: C
ircumstantiality is the what Tom exhibits when he uses overly detailed communication that eventually gets to the
point. He also uses neologism when he makes up new words. Blocking is a sudden stop in speech. Loose
Associations are disconnected thoughts. Confabulation is unconsciously filling in memory gaps with imagined
materials. This is not the same as making up new words. Tangential thoughts are thoughts that veer from the
main idea and never return to it. Derailment occurs when speech is blocked and then begins again on unrelated
topic. Flight of ideas is rapid, fragmented thoughts with pressured speech
Reference: Fontaine. Mental Health Nursing 5th edition
64. Upon admission to the psychiatric unit, a client's behavior indicates severe panic. The client repeatedly
states, "I know the church will kill me. They found out that I'm the son of satan." What should Nurse Isabelle say
to initiate a therapeutic relationship with the client?
a. "You certainly look stressed. Can you tell me about the upsetting events that have occurred in your life
recently?"
b. "Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you
prefer something else?"
c. "You're having very frightening thoughts. I'll help you find ways to cope with this scary thinking."
d. "Hello, ___. I'm going to be caring for you while I'm on duty. You look very frightened, but I'm sure you'll feel
better by tomorrow."
ANSWER: B
The first task during the introductory, or orientation, phase of the nurse-client relationship is to formulate a
contract, which begins with the exchange of names and an explanation of the roles and limits of the relationship.
These tasks should precede the exploration of relevant stressors and new coping mechanisms. Offering false
reassurance is never therapeutic.
65. Ann has been using self-mutilative behavior for a year. As her nurse, how would you best respond to her
behavior?
a. "You will not hurt yourself again. This must be agreed to and followed."
b. "You've been hurting yourself physically and emotionally. We can work together to help you decrease this
behavior."
c. "Your behavior hurts your parents. It is not an acceptable behavior."
d. "Why didn't you get help sooner?"
ANSWER: B
You recognize Ann's pain and her behavior in a nonjudgmental manner and include her in the planning. Option A:
This is not the best response. Limits do need to be set, but this is a statement that cuts off the client. If she fails,
and she probably will, this will lead to more shame for her. Option C: This is not the best response. It has a
judgmental tone. Option D: "Why" questions put the client on the spot.
Reference: Fontaine. Mental Health Nursing 5th edition
66. Jerry, who has self-mutilative behavior, has been asked to keep a journal. What would be the main purpose
of keeping a journal for this client?
a. To provide a list of his daily activities
b. To provide a record of every time Jerry uses self-mutilation and breaks his contract
c. To provide data as to when the client needs medication
d. To help Jerry identify stressors or triggers preceding his self-mutilative behavior
ANSWER: D
This is the main purpose of using the journal for this client. This information will help the client learn about his
behavior, how he uses it, and the effect it has on him and others. Option A: This would not be the main purpose.
Often journals do not even list daily activities. Option B: This is not the purpose. This purpose focuses on the
journal as a way to report his failure. This is a negative approach. Option C: This would not be the purpose.
There is no specific medication for this problem.
Reference: Fontaine. Mental Health Nursing 5th edition
67. Erik has been experiencing delusions. The team is discussing the best interventions to help him when he is
delusional. He comes to you and tells you he is frightened. Which intervention would you select to implement?
a."Don't worry. Your delusions will go away. I have worked with many clients with delusions."
b. "We will give you more medication."
c. "It can be scary to have delusions. I am here to help you, and we will keep you safe. Why don't I sit with you
for a while.
d. "It is time for group. Why don't you go to it. You have missed two sessions."
ANSWER: C
This is the best intervention to implement. You are addressing the client's fear, letting the client know that staff
will support him and keep him safe. Option A: This reassurance is not a helpful intervention. The client is worried,
and you cannot be sure that the delusions will go away. Option B: Erik may require more medication, but this
does not address his concerns. Option D: You are ignoring Erik's feelings and needs at this time.
Reference: Fontaine. Mental Health Nursing 5th edition
68. A 16-year old client, says, "I feel better when I am able to yell and throw things." Why will it be difficult to
get to change his aggressive behavior?
a. He is addicted to aggression.
b. His aggression has become a permanent way of resolving issues.
c. Teenagers tend to enjoy aggressive behavior.
d. Teenagers are affected by peers who may be using aggressive behavior.
ANSWER: A
Since his aggression relieves him, decreasing his frustrations, he has become "addicted" to aggression. Option B:
Aggressive behavior can be modified, and this answer does not address the dynamics of his aggressive behavior.
Option C: This is a broad statement. Option D: This is true, but it is not the best explanation for the client's
behavior.
Reference: Fontaine. Mental Health Nursing 5th edition
69. What is thought to be the reason for the increase in violence in clients with mental disorders?
a. Most clients with mental illness develop aggressive behavior.
b. Medications used to treat mental disorders do not affect aggressive behavior.
c. Clients with mental disorders are not receiving the care they need.
d. Clients with mental illness have an increased rate of substance abuse.
ANSWER: D
This is the reason that is given for the increase in aggressive behavior. The drugs directly affect the brain,
increase exposure to dangerous environments due to drug use, and increased activities through which money is
obtained for drugs. Option A: Aggressive behavior is not found in most clients. Option B: Many of the medications
can help to control aggressive behavior by decreasing anxiety and thought disorders. Option C: In many cases,
clients do not have access to appropriate care; however, this is not the reason given for this increase in violence.
Reference: Fontaine. Mental Health Nursing 5th edition
70. When is the best time to teach Maruja, who has a history of violent behavior, nonviolent coping strategies?
a. During the angry episode
c. When not angry or tense
b. When the client is medicated
d. When Maruja is restrained
ANSWER:
As the client regains control, he or she is encouraged to talk about the situation or triggers that led to the
aggressive behavior. The nurse should help the client relax, perhaps sleep, and return to a calmer state. Option
A: This is not the best time. Can the client learn at this time? Option B: This is not the best time. The client may
not be given medication, and if he is given medication, he may not be alert enough to learn. Option D: This is not
the best time for teaching.
Reference: Fontaine. Mental Health Nursing 5th edition
71. A mental health nurse in a case management role likely would include which of the following interventions?
a. Medication administration
c. Antipsychotic medication prescription
b. Crisis intervention
d. Diagnostic testing
ANSWER: B
The major components of case management are psychosocial rehabilitation, consultation, resource linkage
advocacy, therapy, and crisis intervention. Other options are incorrect.
Reference: Morrison-Valfre. Foundations of Mental Health Care. 4th edition
72. The most important factor in mental health treatment is which of the following?
a. Client's psychiatric diagnosis
c. Client-provider relationship
b. Client's psychiatric medications
d. Client-family relationship
ANSWER: C
The core of mental health treatment is the client-provider contract, which establishes trust.
Reference: Morrison-Valfre. Foundations of Mental Health Care. 4th edition
73. Nurse Isabelle encourages her patient to record on-going thoughts in a daily journal. She reviews the journal
to identify the thought patterns that contribute to feelings of depression and anxiety. Which of the following
conceptual frameworks is she using?
a. Psychodynamic framework
c. Cognitive framework
b. Interpersonal framework
d. Behavioral framework
ANSWER: C
The cognitive approach is based on the idea that thoughts influence behavior and feelings. In this example, the
client must first identify recurrent thought processes that are related to depression and anxiety. Behavioral
approach focuses on identifying and changing particular behaviors by changing the environmental reinforcers that
allow symptoms to persists. The interpersonal framework focuses on the client’s relationships with significant
others and the effects of these relationships on the client’s behavior and symptoms. The psychodynamic
framework focuses on the role of unconscious processes and the way in which these processes influence the
client’s behavior or symptoms.
Reference: Ann Isaacs. Lippincott’s Mental health and Psychiatric Nursing. 4th edition. Pages 30-31
74. Which assumption is consistent with the foundation of behaviorism?
a. All behavior is innate
c. All behavior is maladaptive
b. All behavior is learned
d. All behavior is emotionally based
ANSWER: B
Behavior is the result of past learning, current motivation, and biological differences. A behavioralist believes that
all behavior is learned.
Reference: Morrison-Valfre. Foundations of Mental Health Care. 4th edition
75. Which theory emphasizes the total individual and the innate goodness of human nature?
a. Humanistic theory
b. Behavioral theory
c. Developmental theory
d. Personality theory
ANSWER: A
Humanistic theories emphasize the total individual and the positive aspects of humanity. Option B: Behavioral
therapy is based on the assumption that all behavior is learned. Option C: Developmental theory describes the
relationships among the body, mind, and society during the life cycle. Option D: Freud's theory of personality
development has a theme of sexual instinct growth from newborn to adult.
Reference: Morrison-Valfre. Foundations of Mental Health Care. 4th edition
76. Which of the following defines self-awareness?
a. Perceptions, thoughts, feelings, and actions
c. Dependable and steady behaviors
b. Consciousness of one's personality
d. Ability to exercise capability and accountability
ANSWER: B
Self-awareness is the ability to objectively look within. Option A: Behavior consists of perceptions, thoughts,
feelings, and actions. Option C: The concept of consistency involves behaviors that are regular and dependable.
Option D: Responsible people are capable of making and fulfilling obligations.
Reference: Morrison-Valfre. Foundations of Mental Health Care. 4th edition
SITUATION: A nurse must have a sound knowledge foundation of mental health including the history, advances
in treatment, current issues and his/her roles as a psychiatric nurse.
77. People believed that mental illness was caused by the displeasure of the gods and in fact was punishment for
sins and wrongdoing during the:
a. Ancient Times
b. Middle Ages
c. Renaissance
d. Modern Era
ANSWER: A
A – During the ancient times, it was believed that all things good and evil were caused by “spirits”. They believed
that the sicknesses were caused by the gods and in fact was punished for sins and wrongdoing. Those with
disorders were viewed as being divine or demonic.
B – During the middle ages, it was thought that troubled minds were influenced by the moon and the word
“Lunacy” was associated with mental illness
C – During the Renaissance and reformation periods 1500’s, John Weyer, some consider the first psychiatrist,
began to speak out about mental health and attribute the s/sx to mental illness not witchcraft and demons.
D – There began an active advocacy for people with mental illness. People suffering from Mental illness were
moved from jails and poorhouses into institutions. Institutions were often outside the city with very nice
exteriors.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 4
78. During the period of enlightenment, hospitals were created that offered asylum to the suffering. The person
who spearheaded to reform the treatment of mental illness and instrumental to the opening of those hospitals is:
a. Hildegard Peplau
b. Dorothea Dix
c. Erik Erikson
d. Sigmund Freud
ANSWER: B
Dorothea Dix, from the U.S., began a crusade to reform the treatment of mental illness. She was instrumental to
the opening of 32 state hospitals that offered asylum to the suffering. She believed that the society was obligated
to those who were mentally ill and promoted adequate shelter, nutritious food and warm clothing. The other
options are incorrect.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 5
79. The term deinstitutionalization refers to:
a. Specialized treatment units
c. Moving patients to the community
b. Education of institution staff
d. Combining several institutions
ANSWER: C
The movement toward treating those with mental illness in less restrictive environments gained momentum
during the 1960’s. Deinstitutionalization, a deliberate shift from the institution care in state hospitals to
community facilities, began. Community mental health centers served smaller geographic catchment areas that
provided less restrictive treatment located closer to the person’s home, family and friends.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 5
80. The founder of psychoanalysis is:
a. John Weyer
b. Eric Erikson
c. Harry Stack Sullivan
d. Sigmund Freud
ANSWER: D
D – Sigmund Freud,(1856-1939), the founder of psychoanalysis introduced the idea that unconscious motivation
is important when looking at the causes of mental illness.
A – John Weyer, some consider the first psychiatrist, began to speak out about mental health and attribute the
clinical manifestations to mental illness not witchcraft and demons during the Renaissance period.
B – Erikson formulated the 8 developmental tasks.
C – Along with Clara Thompson, Karen Horney, Erich Fromm, Erik H. Erikson, and Frieda Fromm-Reichmann,
Sullivan laid the groundwork for understanding the individual based on the network of relationships in which he
or she is enmeshed. He developed a theory of psychiatry based on interpersonal relationships where cultural
forces are largely responsible for mental illnesses (see also social psychiatry). In his words, one must pay
attention to the "interactional", not the "intrapsychic". This search for satisfaction via personal involvement with
others led Sullivan to characterize loneliness as the most painful of human experiences. He also extended the
Freudian psychoanalysis to the treatment of patients with severe mental disorders, particularly schizophrenia.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 49
81. Which personality structure finds the rules to control the id and allows the person to function successfully in
the world?
a. Id
b. Ego
c. Super Ego
d. Alter Ego
ANSWER: B
B – Is conscious and operates on the reality principle (person can postpone satisfaction to meet greater needs).
Ego provides some control over the id. It is responsible for controlling impulses and to guide behavior toward
long-term goals. It mediates between the id and superego.
A – Includes primitive urges and instincts such as sexual desires and aggression. According to Freud, the id
intrudes into our dreams and they then become an important source of revealing a person’s fundamental
motives. The Id is like the “Kid” in us. It works on the Pleasure principle. “I want what I want when I want it!”
C – Sometimes referred to as the conscience. This is where the Ego finds the rules it uses to control the id. It
incorporates the values of human society. It acts as a sensor for the id.
D – This is not part of the personality structure proposed by Freud.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 4
82. According to the psychoanalytic theory, the ego has several functions. The primary function of the ego is to:
a. Serve as the source of instinctual drives
c. Operate as a conscience that controls unacceptable drives
b. Stimulate psychic energy
d. Test reality and direct behavior
ANSWER: D
The ego tests reality and directs behavior by mediating between the pleasure-seeking instinctual drives of the id
and the restrictiveness of the superego.
Option A and B - the id is the source of instinctual drives and psychic energy.
Option C - the superego also is called the conscience.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 49
83. Erik Erikson’s theory of personality development emphasizes the importance of:
a. Hereditary Factors
b. Sexual Needs
c. Social Influence
d. Chemical Balance
ANSWER: C
Erik Erikson was a German psychoanalyst who extended Frud’s work on personality development across the life
span while focusing on social development as well as psychological development in the life stages. He described
the “Eight Psychosocial Stages of Development”.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 53
84. The nurse knows that Erik Erikson identified the developmental tasks of the school-age child from 6 to 12
years as:
a. Initiative vs guilt
c. Breaking away vs staying at home
b. Industry vs inferiority
d. Psychosexual impulses vs psychosexual development
ANSWER : B
Erik Erikson was the psychologist who proposed the stages of psychological development. In each stage, the
person must complete a life task that is essential to his or her well-being and mental health. A school-aged child
(6-12 y/o) is in the industry vs inferiority stage. The child has emerging confidence in his/her own abilities and
takes pleasure in accomplishments.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 53
85. Garie talks about her joy in having responsible and accomplished children and recalls challenging career as a
lawyer. She is demonstrating a sense of:
a. Ego integrity
b. Industry
c. Generativity
d. Autonomy
ANSWER: A
Ego integrity
Stage

Virtue

Task

Ego integrity VS Despair (maturity)

Wisdom

Accepting responsibilty for one's self and life

Source: S.L. Videbeck, Psychiatric Mental Health Nursing, 3rd Ed., p. 53

86. According to the Psychoanalytic theory, this is the stage wherein the oedipal complex or the wish to marry
the opposite-sex parent and be rid of the same-sex parent is seen in boys and girls.
a. Oral
b. Anal
c. Phallic
d. Genital
ANSWER: C
Sigmund Freud based his theory of childhood development on the belief that sexual energy or libido was the
driving force of human behavior. He proposed that children go through stages of psychosexual development: oral
(birth to 18 months), anal (18 months to 3 years), phallic (3 – 5 years), latency (5-11 or 13 years) and genital
(11-13). It is during the phallic or oedipal stage that the genitals are the focus of interest, penis envy is common
in girls and oedipal complex and Elektra complex is also seen in boys and girls.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 52
87. Which theoretical model is being applied if the nurse views that mental illness resulted from unresolved
conflicts and childhood trauma?
a. Behavioral theories
b. Humanistic theories
c. Psychoanalytic theories
d. Cognitive theories
ANSWER: C
Psychoanalytic theories support the notion that all human behavior is caused and can be explained. Sigmund
Freud believed that repressed childhood experiences and sexual impulses and desires motivated much human
behavior. Based on his studies, he also concluded that some of the problems of his patients resulted from
childhood trauma, failure to complete tasks of psychosexual development. He said that the neurotic behaviors
resulted from the unresolved conflicts.
A-Behavior is learned through experiences that were repeatedly reinforced
B- Focuses on the needs and drives that motivate people
D- Focuses on the immediate thought processing and how the mind works-how a person perceives and interprets
his or her experience and determines how he/she feels or behaves
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 49
88. According to the neurobiologic theory, this neurotransmitter is implicated in schizophrenia and other
psychoses as well as movement disorders such as Parkinson’s disease.
a. Serotonin
b. Norepinephrine
c. Epinephrine
d. Dopamine
ANSWER: D
Dopamine is the neurotransmitter which has been found to be involved in the control of complex movements,
motivation, cognition and the regulation of emotional responses. It is also implicated in schizophrenia and other
psychoses as well as movement disorders such as Parkinson’s disease.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 20
89. The person who originally developed the concept of milieu therapy is:
a. Erik Erikson
b. Hildregard Peplau
c. Harry Stack Sullivan

d. Jean Piaget
ANSWER: C
Harry Stack Sullivan developed the concept of interpersonal relationships and milieu therapy of the “therapeutic
comminuty of milue”, which regarded the interaction among patients as beneficial and emphasized the role of
interaction to interaction in treatment.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 54
90. According to Maslow’s hierarchy of needs, the need for love and belonging must be met before:
a. Physical Survival
b. Oral Satisfaction
c. Safety And Security
d. Self-Actualization
ANSWER: D
Abraham Maslow was an American psychologist who studied the needs or motivations of the individual. The most
basic needs – the physiological need must be met first. The second level involves safety and security needs while
the third level is love and belonging needs. The fourth level involves the esteem needs while the highest level is
self actualization. Options a, b and c should be met before love and belonging needs while love and belonging
needs should be met before esteem needs and self-actualization.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 57
91. The nurse theorist who developed a model for the therapeutic nurse patient relationship that provided the
first systematic theoretical framework for psychiatric nursing is:
a. Hildegard Peplau
b. Ivan Pavlov
c. Dorothea Orem
d. Carl Rogers
ANSWER: A
Hildegard Peplau was a nurse theorist and clinician who built on Sullivan’s interpersonal theories and developed
the concept of the therapeutic nurse-patient relationship which includes four phase: orientation, identification,
exploitation and resolution.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 55
92. There are four areas of the Johari’s window. The characteristics and qualities that are known only to the self
falls in which area?
a. Quadrant 1
b. Quadrant 2
c. Quadrant 3
d. Quadrant 4
ANSWER: C
Nurses use themselves as a therapeutic tool to establish the therapeutic relationship with clients and to help
clients grow, change and heal. One tool that is useful in learning more about oneself if the Johari window which
creates a word portrait of a person in four areas and indicates how well a person knows himself/herself and
communicates with others.
Quadrant 1- Open or public self
Quadrant 2- Blind or unaware self
Quadrant 3- Private/Hidden self
Quadrant 4- Unknown

Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 95
NURSE PATIENT RELATIONSHIP
93. Nurses must understand themselves to promote their client’s growth and to avoid limiting the client’s choices
to those that nurses value. The therapeutic use of self was described by:
a. Sigmund Freud
b. Hildegard Peplau
c. Harry Sullivan
d. B.F. Skinner
ANSWER: B
Hildegard Peplau, described the therapeutic use of self in the nurse-client relationship. Nurses use themselves as
a therapeutic tool to establish therapeutic relationship with clients by developing self-awareness and beginning to
understand his/her attitudes for the nurse to be able to use aspects of his/her personality, experiences, values,
feelings, intelligence, needs and coping skills to establish relationships with the clients.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 94
94. A therapeutic nurse-patient relationship is described as:
1. It is based on friendship and mutual interest
2. It is a professional relationship
3. It is focused on helping the client solve problems and achieve health-related goals
4. It is maintained only as long as the client requires professional help
a. 1, 2 and 3
b. 1, 2 and 4
c. 2, 3 and 4
d. 1, 3 and 4
ANSWER: C
A therapeutic nurse-patient relationship is described as a professional relationship, focused on helping the client
solve problems and achieve health-related goals and maintained only as long as the client requires professional
help. This differs from social and intimate relationship (such as friendship) because it focuses on the needs,
experiences, feelings and ideas of the client only. The nurse and the client agree about the area to work on and
evaluate the outcomes.
The nurse should constantly focus on the client’s needs and not his/her own.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 97
95. During the orientation phase of the nurse-client relationship, the nurse performs the following activities,
except:
a. Reviews the client’s medical record
b. Establishes a contract with the client regarding expectations and responsibilities
c. The nurse begins to built trust with the client
d. Discusses with the client on the time frame of the relationship
ANSWER: A
Reviewing the client’s records, reading background materials available on the client, becoming familiar with the
client’s medications, paperwork and arranges for a quiet, private and comfortable setting are all part of the preorientation phase.
Options B, C and D are all part of the orientation phase.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 97
96. When the nurse encourages verbalization of feelings and facilitates behavior change in the client, they are in
what phase of the nurse-client relationship?
a. Pre-orientation phase
b. Orientation phase
c. Working Phase
d. Termination Phase
ANSWER: C
The working phase is usually divided into two phases: 1) the problem identification phase wherein the client
identifies the issues and concern causing problems and exploitation phase wherein the nurse guides the client to
examine feelings and responses to develop better coping skills and a more positive self-image.
Specific tasks include: exploring perceptions of reality, developing positive coping mechanisms, encouraging
verbalization of feelings, facilitating behavior change, promoting independence
A- reviewing the client’s charts and medical records
B- Building trust and rapport, setting a contract
C- Problems are resolved and relationship is ended
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 101
97. The essential foundation that must be established early in the therapeutic relationship is:
a. Confidence
b. Insight
c. Trust
d. Empathy
ANSWER: C
The essential foundation that must be established early in the relationship is trust.
If trust is established, it is more likely to succeed and meet established goals.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 99
98. Establishing confidentiality belongs to which phase of the Nurse-Client relationship?
a. Pre-orientation phase
c. Working Phase
b. Orientation phase
d. Termination Phase
ANSWER: B
Confidentiality means respecting the client’s right to keep any private information about his/her mental and
physical health and related care. For the client to feel safe, boundaries must be clear. The nurse must clearly
state the information about who will have access to the client assessment data and progress evaluations. The
establishment of confidentiality occurs during the orientation phase.
Reference: Videbeck, S. (2004) Psychiatric Mental health Nursing. 2nd edition. Lippincott Williams and Wilkins.
Page 99
99. A nurse is assigned to a client who has a domineering and demanding attitude, similar to the nurse’s own
mother. The nurse seeks out a colleague to share feelings about this situation. The nurse’s action indicates:
a. Appropriate self-awareness
c. Lack of knowledge about client’s problems
b. An inability to cope effectively
d. A need to change client assignment
ANSWER: A
Self-awareness is important. Analyzing and sharing perceptions about oneself in relation to a client helps a nurse
work through countertransference feelings, which could hinder therapeutic process. Seeking colleague
consultation regarding difficult interaction does not indicate poor coping or lack of knowledge. If the consultation
with the colleague does not improve the nurse’s ability to interact therapeutically with this client, a change of
assignment may be indicated.
Source: Lippincott’s Review Series Mental Health and Psychiatric Nursing 3rd ed by: Isaacs, Ann, p.15
100. After hearing a client with bulimia talk about her bizarre eating binges of raw pancake batter and bowls of
whipped cream, the nurse feels disgusted and feels like telling her to "snap out of it." Which of the following
would be the action for the nurse at this time?
a. Share these feelings with the client, pointing out that the client's behavior alienates people.
b. Ask the client to talk more about her eating habits, trying to understand her underlying problem.
c. Suggest that another nurse work with the client because this relationship is no longer therapeutic.
d. Discuss these feelings with another nurse or colleague in an attempt to help to resolve them.
ANSWER: D
The nurse is experiencing a countertransference reaction that can only be resolved by self-reflection and
discussion with other professionals.
Option A - It is inappropriate for the nurse to tell the client about her feelings because doing so might perpetuate
the client's low self-esteem.
Option B - Continuing to struggle with the problem feelings without analyzing the nurse's own reactions is
counterproductive.
Option C - Asking another nurse to work with the client may solve the problem momentarily, but the nurse will
most likely encounter similar problems and clients in the future. Additionally, the client may feel rejected by the
nurse if someone else takes over.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 97