45 Questions on Foundations of Nursing
1. The charge nurse in an acute care setting assigns a client, who is on one-to-one suicide precautions, to a psychiatric aide. This assignment is considered:
A. poor nursing practice because a registered nurse should work with this client.
B. reasonable nursing practice because one-to-one requires the total attention of a staff member.
C. outside the responsibility of an aide.
D. illegal to delegate to an aide.
Rationale: A psychiatric aide can sit with the client and provide safety. The nurse is still responsible for assessing the client and ensuring that one-to-one supervision occurs. Aides are capable of providing one-to-one observation. It isn't illegal to delegate observation to an aide.
2. Nursing care for a client after electroconvulsive therapy (ECT) should include:
A. nothing by mouth for 24 hours after the treatment because of the anesthetic agent.
B. bed rest for the first 8 hours after a treatment.
C. assessment of short-term memory loss.
D. no special care.
Rationale: The nurse must assess the level of short-term memory loss. Short-term memory loss is the most common adverse effect of ECT. In most cases, memory returns within 3 months. The client might need to be reoriented. The client can get out of bed and eat as soon as he feels comfortable.
3. The employer of a client on the psychiatric unit calls the nursing station inquiring about the client's progress. The nurse doesn't know if consent has been given by the client to allow the staff to give information out to callers on the phone. Which of the following would be the nurse's best response?
A. "I'm not permitted to discuss her progress."
B. "I'll give you the name and telephone number of her physician."
C. "I'll have her call you."
D. "I can't confirm whether your employee is a client here."
Rationale: The nurse's release of information to the client's employer without the client's consent is a breach of confidentiality. The stigma associated with psychiatric illness may affect the client's employment; therefore, it's better to maintain confidentiality and refrain from disclosing any information about the client, including whether she's a client in the hospital.
4. A nurse is working with a dying client and his family. Which communication technique is most important to use?
A. Reflection
B. Interpretation
C. Clarification
D. Active listening
Rationale: When working with a dying client and his family, the nurse uses active listening to assess their feelings, coping skills, and immediate and long-term needs. It also helps the nurse select other appropriate strategies, such as reflection and clarification. Interpretation should be used sparingly to avoid making false inferences or putting the client on the defensive.
5. Which clinical condition meets the criteria for involuntary commitment?
A. A single parent who leaves her minor children unattended and stays out all night drinking
B. A person who lives alone and isn't able to care for himself and has schizophrenia with delusions of persecution
C. A man who threatens to kill his wife
D. A person with depression who says he's tired of living but doesn't have a suicide plan
Rationale: One of the criteria for involuntary commitment is an emergency in which the client is a threat to himself or others. A parent might have a child removed from the home because of neglect, but that doesn't meet the criteria for involuntary commitment. Many individuals with schizophrenia can learn to live with hallucinations and delusions and don't require hospitalization. To meet criteria for involuntary commitment, a depressed individual must have a suicide plan and be a direct threat to himself.
6. A client in the emergency department complains of suicidal ideation and feelings of worthlessness. He has a family history of suicide. The nurse is assessing the client to determine treatment recommendations. The most important factor to consider is:
A. an active suicide plan and the means to carry it out.
B. a previous suicide attempt.
C. the client's religion and social status.
D. social support and marital status.
Rationale: The presence of an actual plan would require a restrictive environment for the client. Although a previous suicide attempt, marital status, and social support can affect the rate of suicide, a serious plan is of primary concern for the nurse.
7. 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
Rationale: The nurse is using focusing by suggesting that the client discuss a specific issue. She didn't restate the question, ask further questions (exploring), and didn't make an observation.
8. A client refuses his evening dose of haloperidol (Haldol) then becomes extremely agitated in the day room while other clients are watching television. He begins cursing and throwing furniture. The nurse's first action is to:
A. check the client's medical record for an order for an I.M. as needed dose of medication for agitation.
B. place the client in full leather restraints.
C. call the physician and report the behavior.
D. remove all other clients from the day room.
Rationale: The nurse's first priority is to consider the safety of the clients in the therapeutic setting. The other actions are appropriate responses after ensuring the safety of other individuals.
9. The nurse is assessing a client for lifestyle factors that might affect normal coping. Which factor would the nurse most likely consider?
A. Inadequate diet
B. Divorce
C. Job promotion
D. Adopting a child
Rationale: Poor, inadequate diet is the only option considered a lifestyle factor. The other choices — divorce, job promotion, and adopting a child — are considered life events.
10. 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 of the following techniques?
A. A broad opening statement
B. Reassurance
C. Clarifying
D. Making observations
Rationale: The nurse is using observation to give the client feedback about his behavior and attitude. A broad statement doesn't give feedback to the client. The nurse didn't ask the client to explain his actions (clarifying) and she didn't reassure the client.
11. The nurse is caring for a 40-year-old client. Which behavior by the client indicates adult cognitive development?
A. Has perceptions based on reality
B. Assumes responsibility for actions
C. Generates new levels of awareness
D. Has maximum ability to solve problems and learn new skills
Rationale: Adults between ages 31 and 45 generate new levels of awareness. Having perceptions based on reality and assuming responsibility for actions indicate socialization development — not cognitive development. Demonstrating maximum ability to solve problems and learning new skills occur in young adults between ages 20 and 30.
12. Touching other people without their permission, reading someone else's mail, and using personal possessions without asking permission are all examples of:
A. antisocial behavior.
B. manipulation.
C. poor boundaries.
D. passive-aggressive behavior.
Rationale: The described behaviors indicate poor personal boundaries, which is the inability to differentiate between self and others. Poor boundaries are symptoms of antisocial and passive-aggressive behavior. Manipulation is an attempt to control another person.
13. The nurse is caring for a client who is suicidal. When accompanying the client to the bathroom, the nurse should:
A. give him privacy in the bathroom.
B. allow him to shave.
C. open the window and allow him to get some fresh air.
D. observe him.
Rationale: The nurse has a responsibility to observe continuously the acutely suicidal client — not provide privacy. The nurse should watch for clues, such as communicating suicidal thoughts, threats, and messages; hoarding medications; and talking about death. By accompanying the client to the bathroom, the nurse will naturally prevent hanging or other injury. The nurse will check the client's area and fix dangerous conditions, such as exposed pipes and windows without safety glass. The nurse will also remove potentially dangerous objects such as belts, razors, suspenders, glass, and knives.
14. Silence in therapeutic communication is:
A. a means of disapproval.
B. to be avoided as it indicates intolerance and anger.
C. a means of allowing the client space in which to respond and communicates patience.
D. not therapeutic.
Rationale: Silence conveys acceptance and gives the client an opportunity to reflect. It doesn't convey disapproval unless accompanied by hostile gestures. It's one of the most difficult therapeutic communication techniques.
15. The nurse at a substance abuse center answers the phone. A probation officer asks if a client is in treatment. The nurse responds, "No, the client you're looking for isn't here." Which of the following statements best describes the nurse's response?
A. Correct because she didn't give out information about the client
B. A violation of confidentiality because she informed the officer that the client wasn't there
C. A breech of the principle of veracity because the nurse is misleading the officer
D. Illegal because she's withholding information from law enforcement agents
Rationale: The nurse violated confidentiality by informing the officer that the client wasn't in treatment. Even with law enforcement agents, the nurse must be a client advocate and protect the client's confidentiality. Information can be legally withheld when a court order isn't in place.
16. Two nurses are discussing a client's condition in the elevator. The employer of the mentioned client overhears the conversation and fires the client. The nurses may be liable for which of the following accusations?
A. Assault
B. Battery
C. Neglect
D. Breach of confidentiality
Rationale: Breach of confidentiality occurs when a nurse shares information that can cause harm to an individual. Assault is an act that results in fear that one will be touched without consent. Battery involves unconsented touching of another person. Neglect is the failure to do what is deemed reasonable in a situation.
17. A 26-year-old male is admitted to an inpatient psychiatric hospital after having been picked up by the local police while walking around the neighborhood at night without shoes in the snow. He appears confused and disoriented. Which of the following is the most immediate nursing action?
A. Assess and stabilize the client’s medical needs.
B. Assess and stabilize the client’s psychological needs.
C. Attempt to locate the nearest family member to get an accurate history.
D. Arrange a transfer to the nearest medical facility.
Rationale: The possibility of frostbite must be evaluated before the other interventions. Options B, C, and D don’t address the client’s immediate medical needs.
18. Sedative-hypnotic drugs are used to treat which of the following disorders?
A. Obsessive-compulsive disorder (OCD)
B. Attention deficit hyperactivity disorder (ADHD)
C. Hallucinations and delusions
D. Anxiety and insomnia
Rationale: Sedative-hypnotic drugs aren't linked to the treatment of a specific disorder. They're used to treat anxiety and insomnia, which can occur in a range of psychiatric disorders. Antidepressants are used to treat OCD. Psychostimulants are used to treat ADHD. Hallucinations and delusions are treated with antipsychotics.
19. Assertive behavior involves which of the following elements?
A. Saying what is on your mind at the expense of others
B. Expressing an air of superiority
C. Avoiding unpleasant situations and circumstances
D. Standing up for your rights while respecting the rights of others
Rationale: The basic element of assertive behavior includes the ability to express your feelings and thoughts while respecting the rights of others. Options A and B describe aggressive behavior, and option C describes passive behavior.
20. 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
B. Tachycardia, weight loss, and mood swings
C. Hypotension, weight gain, and listlessness
D. Increased appetite, slowing of sensorium, and arrhythmias
Rationale: Stimulants produce mood swings, weight loss, and tachycardia. The other symptoms indicate CNS depression.
21. A client receiving morphine for long-term pain management develops tolerance. Tolerance is defined as:
A. an increased response to a medication.
B. a diminished response to a drug so that more is required to reach the same effect.
C. an allergic reaction to a medication.
D. an ability to take the same drug for extended periods of time.
Rationale: Tolerance occurs when the body requires higher doses of substances, such as alcohol, opioids, or benzodiazepines, to achieve desired effects. Increased response indicates a need for less of a drug to achieve the same effects. Allergic reactions are autoimmune responses to a particular drug or class of drugs.
22. The third major health problem in the United States is which of the following disorders?
A. Cancer
B. Heart disease
C. Alcoholism
D. Bipolar illness
Rationale: Alcoholism is the third major health problem in the United States. Between 9 and 10 million people are "problem" drinkers. In addition, alcoholism adversely affects the mental health of 30 million friends and relatives of alcoholics. Heart disease and cancer are the number one and two health problems, respectively, in the United States. Bipolar illness isn't a major illness.
23. 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.
B. supportive environment.
C. abuse and neglect.
D. direction and attention.
Rationale: 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.
24. A client in an acute care center lacerates her wrists. She has a history of conflicts and acting out. The client tells the nurse, "I did a good job didn't I?" Which of the following responses would be best?
A. "You sure did. You're going to have a scar now."
B. "How many times have you done this before?"
C. "What were you feeling before you hurt yourself?"
D. "It seems to me you are trying to get attention in a negative way."
Rationale: Self-mutilation is the client's way of defending herself against feelings she isn't able to express. It's important to shift focus from the mutilation and to help the client express feelings in a more acceptable manner. All other answers are judgmental.
25. Which of the following statements is a guideline to help nurses avoid liability?
A. Follow every physician's order.
B. Do what the client desires even though you may disagree.
C. Practice within the scope of the Nurse Practice Act.
D. Obtain malpractice insurance.
Rationale: The Nurse Practice Act outlines acceptable standards for nursing. Practicing within those guidelines will protect the nurse from liability. The client doesn't know standards of care and isn't responsible for the nurse's actions. Physicians may not be aware of guidelines for nurses and delegate inappropriate treatment or practice for the nurse. Insurance won't prevent a liability suit, but only assist the nurse if a suit would be filed.
26. What is the nurse's most important role in caring for a client with a mental health disorder?
A. To offer advice
B. To know how to solve the client's problems
C. To establish trust and rapport
D. To set limits with the client
Rationale: 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.
27. A voluntary client in a health care facility decides to leave the unit before treatment is complete. To detain the client, the nurse refuses to return the client's personal effects. This is an example of which of the following?
A. False imprisonment
B. Limit setting
C. Slander
D. Violation of confidentiality
Rationale: Confining a voluntary client against his will may be considered false imprisonment. Slander is oral defamation of character. The nurse hasn't given out any information about the client, so confidentiality hasn't been violated.
28. A client in an acute care setting tells the nurse, "I don't think I can face going home tomorrow." The nurse replies, "Do you want to talk more about it?" The nurse is using which of the following techniques?
A. Presenting reality
B. Making observations
C. Restating
D. Exploring
Rationale: The nurse is using the technique of exploring because she's willing to delve further into the client's concern. She isn't presenting reality or making observations or simply restating. The nurse is encouraging the client to explore his feelings.
29. The goal of crisis intervention is:
A. to solve the client's problems for him.
B. psychological resolution of the immediate crisis.
C. to establish a means for long-term therapy.
D. to provide a means for admission to an acute care facility.
Rationale: The goal of crisis intervention is the resolution of an immediate problem. The client must learn to solve his own issues. Although some clients do enter long-term therapy or are admitted to an acute care facility, long-term therapy isn't the goal of crisis intervention.
30. The nurse's goal in crisis intervention is to provide:
A. problem-solving techniques and structured activities.
B. an insight-oriented analytic approach.
C. medication to sedate the client.
D. nondirective techniques such as free association.
Rationale: Individuals in a crisis need immediate assistance. They're unable to solve problems and need structure and assistance in accessing resources. Clients in a crisis don't need lengthy explanations or have time to develop insight on their own. They might need medication but, in most cases, support and direction can be most helpful.
31. Additive central nervous system (CNS) depression can occur when combining a sedative-hypnotic with which of the following drugs?
A. methylphenidate (Ritalin)
B. cocaine
C. amitriptyline (Elavil)
D. amphetamine (Adderall)
Rationale: 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.
32. A client in an acute care mental health program refuses his morning dose of an oral antipsychotic medication and believes he's being poisoned. The nurse should respond by taking which of the following actions?
A. Administering the medication by injection
B. Omitting the dose and trying again the next day
C. Crushing the medication and putting it in his food
D. Consulting with the physician about a plan of care
Rationale: To determine plans of care for clients who are noncompliant with medications, the nurse should consult with the physician. Unless the client presents a danger to himself or others, medications can't be forced on a client. A dose shouldn’t be omitted without first checking with the physician. Intentionally deceiving or misleading a client violates the therapeutic relationship.
33. Which of the following statements accurately describes therapeutic communication?
A. Offering advice and your opinion
B. Refraining from verbalizing your feelings
C. Avoiding advice, judgment, false reassurance, and approval
D. Telling the client how to cope
Rationale: The goal of therapeutic communication is to help the client develop insight and skills to solve his own problems. This is done by avoiding advice, judgment, false reassurance, and approval. Pointing out mistakes can make a client defensive. The client-nurse relationship isn't the place for the nurse to offer advice or an opinion. It also isn't the place for the nurse to verbalize her own feelings. The client needs assistance in developing coping skills, not someone to solve problems for him.
34. Your client is taking clozapine (Clozaril) and complains of a sore throat. This symptom may be an indication of which of the following adverse reactions?
A. Extrapyramidal reaction
B. Tardive dyskinesia
C. Reye's syndrome
D. Agranulocytosis
Rationale: The complaint of a sore throat may indicate an infection caused by agranulocytosis, a depletion in white blood cells. Although extrapyramidal reaction and tardive dyskinesia may occur, a sore throat isn't an indication of these conditions. Reye's syndrome is caused by a virus unrelated to clozapine.
35. A therapeutic nurse-client relationship begins with the nurse’s:
A. sincere desire to help others.
B. acceptance of others.
C. self-awareness and understanding.
D. sound knowledge of psychiatric nursing.
Rationale: Although all of the choices are desirable, knowledge of self is the basis for building a strong, therapeutic nurse-client relationship. Being aware of and understanding personal feelings and behavior is a prerequisite for understanding and helping clients.
36. A nurse places a client in full leather restraints. How often must the nurse check the client's circulation?
A. Once per hour
B. Once per shift
C. Every 10 to 15 minutes
D. Every 2 hours
Rationale: Circulatory as well as skin and nerve damage can occur within 15 minutes. Checking every hour, 2 hours, or 8 hours isn't often enough and could result in permanent damage to the client's extremities.
37. A woman seeking help at a community mental health center complains of fatigue, sensitivity to criticism, decreased libido, and feeling self-conscious. She also has aches and pains. A nursing diagnosis for this client might include:
A. Delayed growth and development.
B. Ineffective role performance.
C. Posttrauma syndrome.
D. Chronic low self-esteem.
Rationale: All symptoms define chronic low self-esteem. There isn't enough information to determine delayed growth and development. The question doesn't describe the client's ability to perform in her roles. Posttrauma syndrome occurs after experiencing a traumatic event and doesn't coincide with the data in the question.
38. An agitated client demands to see her chart so she can read what has been written about her. Which of the following statements is the nurse's best response to the client?
A. "I'm sorry the chart is the property of the facility. We don't permit clients to read them."
B. "You have the right to see your chart. Please discuss this with your primary care provider."
C. "You may see your chart after you're discharged."
D. "Please discuss this matter with your attorney."
Rationale: The Bill of Rights for Psychiatric Clients includes the right for clients to access their medical records unless doing so would be detrimental to their health. To determine if information might be detrimental to the client, the primary care provider should be informed of the client's request. The client doesn't need an attorney to view her chart. She also doesn't need to wait until after discharge to view it.
39. 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 1 hour
B. Never
C. If a voluntary client wants to leave against medical advice
D. When a minor child is out of control
Rationale: The primary physician in charge of a client's care must write an order for the restraint within 1 hour. 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.
40. The nurse is caring for a client diagnosed with body dysmorphic disorder. When the client verbalizes disapproval of her physical features, the nurse should:
A. encourage verbalizations about fears and stressful life situations.
B. agree with the client because she feels a specific physical feature is awful.
C. ignore the comment and talk about less threatening issues.
D. compliment the client on her appearance.
Rationale: Encouraging the client to discuss stressful life situations helps focus on the underlying issues. The client's preoccupation with a specific physical feature is a means of not coping with life. Ignoring the client or complimenting the client won't be helpful. She won't be able to accept the compliment. Agreeing with her strengthens her problem.
41. In a group therapy setting, one member is very demanding, repeatedly interrupting others, and taking most of the group time. The nurse's best response would be:
A. "Will you briefly summarize your point because others need time also?"
B. "Your behavior is obnoxious and drains the group."
C. To ignore the behavior and allow him to vent.
D. "I'm so frustrated with your behavior."
Rationale: Option A redirects the client to focus his comments and allows him to make his point. Option B is judgmental, and option C doesn't help facilitate communication. Option D focuses more on the nurse than on the client's need.
42. The nurse must assess judgment to determine a client's mental status. Which test best accomplishes this?
A. Interpreting proverbs
B. Spelling words backward
C. Counting by serial sevens
D. Discussing hypothetical ethical situations
Rationale: Hypothetical ethical situations — such as "What would you do if you found a wallet containing credit cards and identification?" — are used to test judgment. Proverb interpretation tests thinking. Spelling words backward and counting by serial sevens test concentration.
43. Which of the following statements describes how elderly clients react to medications?
A. At risk for increased adverse effects
B. Tolerate medication better because they're less active
C. Metabolize medications quickly
D. Need higher doses to respond to the same medication
Rationale: As individuals become older, their livers metabolize drugs at a slower rate. Cumulative effects can occur and increase the risk of adverse effects. Elderly clients typically need lower doses not higher. Level of activity typically doesn't affect a person's reaction to medication.
44. Which of the following indications is the primary use for electroconvulsive therapy (ECT)?
A. Severe agitation
B. Antisocial behavior
C. Noncompliance with treatment
D. Major depression with psychotic features
Rationale: ECT is indicated for depression. ECT isn't indicated for severe agitation, antisocial behavior, or treatment noncompliance.
45. Conditions necessary for the development of a positive sense of self-esteem include:
A. consistent limits.
B. critical environment.
C. inconsistent boundaries.
D. physical discipline.
Rationale: A structured lifestyle demonstrates acceptance and caring and provides a sense of security. A critical environment erodes a person's esteem. Inconsistent boundaries lead to feelings of insecurity and lack of concern. Physical discipline can decrease self-esteem.
A. poor nursing practice because a registered nurse should work with this client.
B. reasonable nursing practice because one-to-one requires the total attention of a staff member.
C. outside the responsibility of an aide.
D. illegal to delegate to an aide.
Rationale: A psychiatric aide can sit with the client and provide safety. The nurse is still responsible for assessing the client and ensuring that one-to-one supervision occurs. Aides are capable of providing one-to-one observation. It isn't illegal to delegate observation to an aide.
2. Nursing care for a client after electroconvulsive therapy (ECT) should include:
A. nothing by mouth for 24 hours after the treatment because of the anesthetic agent.
B. bed rest for the first 8 hours after a treatment.
C. assessment of short-term memory loss.
D. no special care.
Rationale: The nurse must assess the level of short-term memory loss. Short-term memory loss is the most common adverse effect of ECT. In most cases, memory returns within 3 months. The client might need to be reoriented. The client can get out of bed and eat as soon as he feels comfortable.
3. The employer of a client on the psychiatric unit calls the nursing station inquiring about the client's progress. The nurse doesn't know if consent has been given by the client to allow the staff to give information out to callers on the phone. Which of the following would be the nurse's best response?
A. "I'm not permitted to discuss her progress."
B. "I'll give you the name and telephone number of her physician."
C. "I'll have her call you."
D. "I can't confirm whether your employee is a client here."
Rationale: The nurse's release of information to the client's employer without the client's consent is a breach of confidentiality. The stigma associated with psychiatric illness may affect the client's employment; therefore, it's better to maintain confidentiality and refrain from disclosing any information about the client, including whether she's a client in the hospital.
4. A nurse is working with a dying client and his family. Which communication technique is most important to use?
A. Reflection
B. Interpretation
C. Clarification
D. Active listening
Rationale: When working with a dying client and his family, the nurse uses active listening to assess their feelings, coping skills, and immediate and long-term needs. It also helps the nurse select other appropriate strategies, such as reflection and clarification. Interpretation should be used sparingly to avoid making false inferences or putting the client on the defensive.
5. Which clinical condition meets the criteria for involuntary commitment?
A. A single parent who leaves her minor children unattended and stays out all night drinking
B. A person who lives alone and isn't able to care for himself and has schizophrenia with delusions of persecution
C. A man who threatens to kill his wife
D. A person with depression who says he's tired of living but doesn't have a suicide plan
Rationale: One of the criteria for involuntary commitment is an emergency in which the client is a threat to himself or others. A parent might have a child removed from the home because of neglect, but that doesn't meet the criteria for involuntary commitment. Many individuals with schizophrenia can learn to live with hallucinations and delusions and don't require hospitalization. To meet criteria for involuntary commitment, a depressed individual must have a suicide plan and be a direct threat to himself.
6. A client in the emergency department complains of suicidal ideation and feelings of worthlessness. He has a family history of suicide. The nurse is assessing the client to determine treatment recommendations. The most important factor to consider is:
A. an active suicide plan and the means to carry it out.
B. a previous suicide attempt.
C. the client's religion and social status.
D. social support and marital status.
Rationale: The presence of an actual plan would require a restrictive environment for the client. Although a previous suicide attempt, marital status, and social support can affect the rate of suicide, a serious plan is of primary concern for the nurse.
7. 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
Rationale: The nurse is using focusing by suggesting that the client discuss a specific issue. She didn't restate the question, ask further questions (exploring), and didn't make an observation.
8. A client refuses his evening dose of haloperidol (Haldol) then becomes extremely agitated in the day room while other clients are watching television. He begins cursing and throwing furniture. The nurse's first action is to:
A. check the client's medical record for an order for an I.M. as needed dose of medication for agitation.
B. place the client in full leather restraints.
C. call the physician and report the behavior.
D. remove all other clients from the day room.
Rationale: The nurse's first priority is to consider the safety of the clients in the therapeutic setting. The other actions are appropriate responses after ensuring the safety of other individuals.
9. The nurse is assessing a client for lifestyle factors that might affect normal coping. Which factor would the nurse most likely consider?
A. Inadequate diet
B. Divorce
C. Job promotion
D. Adopting a child
Rationale: Poor, inadequate diet is the only option considered a lifestyle factor. The other choices — divorce, job promotion, and adopting a child — are considered life events.
10. 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 of the following techniques?
A. A broad opening statement
B. Reassurance
C. Clarifying
D. Making observations
Rationale: The nurse is using observation to give the client feedback about his behavior and attitude. A broad statement doesn't give feedback to the client. The nurse didn't ask the client to explain his actions (clarifying) and she didn't reassure the client.
11. The nurse is caring for a 40-year-old client. Which behavior by the client indicates adult cognitive development?
A. Has perceptions based on reality
B. Assumes responsibility for actions
C. Generates new levels of awareness
D. Has maximum ability to solve problems and learn new skills
Rationale: Adults between ages 31 and 45 generate new levels of awareness. Having perceptions based on reality and assuming responsibility for actions indicate socialization development — not cognitive development. Demonstrating maximum ability to solve problems and learning new skills occur in young adults between ages 20 and 30.
12. Touching other people without their permission, reading someone else's mail, and using personal possessions without asking permission are all examples of:
A. antisocial behavior.
B. manipulation.
C. poor boundaries.
D. passive-aggressive behavior.
Rationale: The described behaviors indicate poor personal boundaries, which is the inability to differentiate between self and others. Poor boundaries are symptoms of antisocial and passive-aggressive behavior. Manipulation is an attempt to control another person.
13. The nurse is caring for a client who is suicidal. When accompanying the client to the bathroom, the nurse should:
A. give him privacy in the bathroom.
B. allow him to shave.
C. open the window and allow him to get some fresh air.
D. observe him.
Rationale: The nurse has a responsibility to observe continuously the acutely suicidal client — not provide privacy. The nurse should watch for clues, such as communicating suicidal thoughts, threats, and messages; hoarding medications; and talking about death. By accompanying the client to the bathroom, the nurse will naturally prevent hanging or other injury. The nurse will check the client's area and fix dangerous conditions, such as exposed pipes and windows without safety glass. The nurse will also remove potentially dangerous objects such as belts, razors, suspenders, glass, and knives.
14. Silence in therapeutic communication is:
A. a means of disapproval.
B. to be avoided as it indicates intolerance and anger.
C. a means of allowing the client space in which to respond and communicates patience.
D. not therapeutic.
Rationale: Silence conveys acceptance and gives the client an opportunity to reflect. It doesn't convey disapproval unless accompanied by hostile gestures. It's one of the most difficult therapeutic communication techniques.
15. The nurse at a substance abuse center answers the phone. A probation officer asks if a client is in treatment. The nurse responds, "No, the client you're looking for isn't here." Which of the following statements best describes the nurse's response?
A. Correct because she didn't give out information about the client
B. A violation of confidentiality because she informed the officer that the client wasn't there
C. A breech of the principle of veracity because the nurse is misleading the officer
D. Illegal because she's withholding information from law enforcement agents
Rationale: The nurse violated confidentiality by informing the officer that the client wasn't in treatment. Even with law enforcement agents, the nurse must be a client advocate and protect the client's confidentiality. Information can be legally withheld when a court order isn't in place.
16. Two nurses are discussing a client's condition in the elevator. The employer of the mentioned client overhears the conversation and fires the client. The nurses may be liable for which of the following accusations?
A. Assault
B. Battery
C. Neglect
D. Breach of confidentiality
Rationale: Breach of confidentiality occurs when a nurse shares information that can cause harm to an individual. Assault is an act that results in fear that one will be touched without consent. Battery involves unconsented touching of another person. Neglect is the failure to do what is deemed reasonable in a situation.
17. A 26-year-old male is admitted to an inpatient psychiatric hospital after having been picked up by the local police while walking around the neighborhood at night without shoes in the snow. He appears confused and disoriented. Which of the following is the most immediate nursing action?
A. Assess and stabilize the client’s medical needs.
B. Assess and stabilize the client’s psychological needs.
C. Attempt to locate the nearest family member to get an accurate history.
D. Arrange a transfer to the nearest medical facility.
Rationale: The possibility of frostbite must be evaluated before the other interventions. Options B, C, and D don’t address the client’s immediate medical needs.
18. Sedative-hypnotic drugs are used to treat which of the following disorders?
A. Obsessive-compulsive disorder (OCD)
B. Attention deficit hyperactivity disorder (ADHD)
C. Hallucinations and delusions
D. Anxiety and insomnia
Rationale: Sedative-hypnotic drugs aren't linked to the treatment of a specific disorder. They're used to treat anxiety and insomnia, which can occur in a range of psychiatric disorders. Antidepressants are used to treat OCD. Psychostimulants are used to treat ADHD. Hallucinations and delusions are treated with antipsychotics.
19. Assertive behavior involves which of the following elements?
A. Saying what is on your mind at the expense of others
B. Expressing an air of superiority
C. Avoiding unpleasant situations and circumstances
D. Standing up for your rights while respecting the rights of others
Rationale: The basic element of assertive behavior includes the ability to express your feelings and thoughts while respecting the rights of others. Options A and B describe aggressive behavior, and option C describes passive behavior.
20. 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
B. Tachycardia, weight loss, and mood swings
C. Hypotension, weight gain, and listlessness
D. Increased appetite, slowing of sensorium, and arrhythmias
Rationale: Stimulants produce mood swings, weight loss, and tachycardia. The other symptoms indicate CNS depression.
21. A client receiving morphine for long-term pain management develops tolerance. Tolerance is defined as:
A. an increased response to a medication.
B. a diminished response to a drug so that more is required to reach the same effect.
C. an allergic reaction to a medication.
D. an ability to take the same drug for extended periods of time.
Rationale: Tolerance occurs when the body requires higher doses of substances, such as alcohol, opioids, or benzodiazepines, to achieve desired effects. Increased response indicates a need for less of a drug to achieve the same effects. Allergic reactions are autoimmune responses to a particular drug or class of drugs.
22. The third major health problem in the United States is which of the following disorders?
A. Cancer
B. Heart disease
C. Alcoholism
D. Bipolar illness
Rationale: Alcoholism is the third major health problem in the United States. Between 9 and 10 million people are "problem" drinkers. In addition, alcoholism adversely affects the mental health of 30 million friends and relatives of alcoholics. Heart disease and cancer are the number one and two health problems, respectively, in the United States. Bipolar illness isn't a major illness.
23. 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.
B. supportive environment.
C. abuse and neglect.
D. direction and attention.
Rationale: 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.
24. A client in an acute care center lacerates her wrists. She has a history of conflicts and acting out. The client tells the nurse, "I did a good job didn't I?" Which of the following responses would be best?
A. "You sure did. You're going to have a scar now."
B. "How many times have you done this before?"
C. "What were you feeling before you hurt yourself?"
D. "It seems to me you are trying to get attention in a negative way."
Rationale: Self-mutilation is the client's way of defending herself against feelings she isn't able to express. It's important to shift focus from the mutilation and to help the client express feelings in a more acceptable manner. All other answers are judgmental.
25. Which of the following statements is a guideline to help nurses avoid liability?
A. Follow every physician's order.
B. Do what the client desires even though you may disagree.
C. Practice within the scope of the Nurse Practice Act.
D. Obtain malpractice insurance.
Rationale: The Nurse Practice Act outlines acceptable standards for nursing. Practicing within those guidelines will protect the nurse from liability. The client doesn't know standards of care and isn't responsible for the nurse's actions. Physicians may not be aware of guidelines for nurses and delegate inappropriate treatment or practice for the nurse. Insurance won't prevent a liability suit, but only assist the nurse if a suit would be filed.
26. What is the nurse's most important role in caring for a client with a mental health disorder?
A. To offer advice
B. To know how to solve the client's problems
C. To establish trust and rapport
D. To set limits with the client
Rationale: 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.
27. A voluntary client in a health care facility decides to leave the unit before treatment is complete. To detain the client, the nurse refuses to return the client's personal effects. This is an example of which of the following?
A. False imprisonment
B. Limit setting
C. Slander
D. Violation of confidentiality
Rationale: Confining a voluntary client against his will may be considered false imprisonment. Slander is oral defamation of character. The nurse hasn't given out any information about the client, so confidentiality hasn't been violated.
28. A client in an acute care setting tells the nurse, "I don't think I can face going home tomorrow." The nurse replies, "Do you want to talk more about it?" The nurse is using which of the following techniques?
A. Presenting reality
B. Making observations
C. Restating
D. Exploring
Rationale: The nurse is using the technique of exploring because she's willing to delve further into the client's concern. She isn't presenting reality or making observations or simply restating. The nurse is encouraging the client to explore his feelings.
29. The goal of crisis intervention is:
A. to solve the client's problems for him.
B. psychological resolution of the immediate crisis.
C. to establish a means for long-term therapy.
D. to provide a means for admission to an acute care facility.
Rationale: The goal of crisis intervention is the resolution of an immediate problem. The client must learn to solve his own issues. Although some clients do enter long-term therapy or are admitted to an acute care facility, long-term therapy isn't the goal of crisis intervention.
30. The nurse's goal in crisis intervention is to provide:
A. problem-solving techniques and structured activities.
B. an insight-oriented analytic approach.
C. medication to sedate the client.
D. nondirective techniques such as free association.
Rationale: Individuals in a crisis need immediate assistance. They're unable to solve problems and need structure and assistance in accessing resources. Clients in a crisis don't need lengthy explanations or have time to develop insight on their own. They might need medication but, in most cases, support and direction can be most helpful.
31. Additive central nervous system (CNS) depression can occur when combining a sedative-hypnotic with which of the following drugs?
A. methylphenidate (Ritalin)
B. cocaine
C. amitriptyline (Elavil)
D. amphetamine (Adderall)
Rationale: 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.
32. A client in an acute care mental health program refuses his morning dose of an oral antipsychotic medication and believes he's being poisoned. The nurse should respond by taking which of the following actions?
A. Administering the medication by injection
B. Omitting the dose and trying again the next day
C. Crushing the medication and putting it in his food
D. Consulting with the physician about a plan of care
Rationale: To determine plans of care for clients who are noncompliant with medications, the nurse should consult with the physician. Unless the client presents a danger to himself or others, medications can't be forced on a client. A dose shouldn’t be omitted without first checking with the physician. Intentionally deceiving or misleading a client violates the therapeutic relationship.
33. Which of the following statements accurately describes therapeutic communication?
A. Offering advice and your opinion
B. Refraining from verbalizing your feelings
C. Avoiding advice, judgment, false reassurance, and approval
D. Telling the client how to cope
Rationale: The goal of therapeutic communication is to help the client develop insight and skills to solve his own problems. This is done by avoiding advice, judgment, false reassurance, and approval. Pointing out mistakes can make a client defensive. The client-nurse relationship isn't the place for the nurse to offer advice or an opinion. It also isn't the place for the nurse to verbalize her own feelings. The client needs assistance in developing coping skills, not someone to solve problems for him.
34. Your client is taking clozapine (Clozaril) and complains of a sore throat. This symptom may be an indication of which of the following adverse reactions?
A. Extrapyramidal reaction
B. Tardive dyskinesia
C. Reye's syndrome
D. Agranulocytosis
Rationale: The complaint of a sore throat may indicate an infection caused by agranulocytosis, a depletion in white blood cells. Although extrapyramidal reaction and tardive dyskinesia may occur, a sore throat isn't an indication of these conditions. Reye's syndrome is caused by a virus unrelated to clozapine.
35. A therapeutic nurse-client relationship begins with the nurse’s:
A. sincere desire to help others.
B. acceptance of others.
C. self-awareness and understanding.
D. sound knowledge of psychiatric nursing.
Rationale: Although all of the choices are desirable, knowledge of self is the basis for building a strong, therapeutic nurse-client relationship. Being aware of and understanding personal feelings and behavior is a prerequisite for understanding and helping clients.
36. A nurse places a client in full leather restraints. How often must the nurse check the client's circulation?
A. Once per hour
B. Once per shift
C. Every 10 to 15 minutes
D. Every 2 hours
Rationale: Circulatory as well as skin and nerve damage can occur within 15 minutes. Checking every hour, 2 hours, or 8 hours isn't often enough and could result in permanent damage to the client's extremities.
37. A woman seeking help at a community mental health center complains of fatigue, sensitivity to criticism, decreased libido, and feeling self-conscious. She also has aches and pains. A nursing diagnosis for this client might include:
A. Delayed growth and development.
B. Ineffective role performance.
C. Posttrauma syndrome.
D. Chronic low self-esteem.
Rationale: All symptoms define chronic low self-esteem. There isn't enough information to determine delayed growth and development. The question doesn't describe the client's ability to perform in her roles. Posttrauma syndrome occurs after experiencing a traumatic event and doesn't coincide with the data in the question.
38. An agitated client demands to see her chart so she can read what has been written about her. Which of the following statements is the nurse's best response to the client?
A. "I'm sorry the chart is the property of the facility. We don't permit clients to read them."
B. "You have the right to see your chart. Please discuss this with your primary care provider."
C. "You may see your chart after you're discharged."
D. "Please discuss this matter with your attorney."
Rationale: The Bill of Rights for Psychiatric Clients includes the right for clients to access their medical records unless doing so would be detrimental to their health. To determine if information might be detrimental to the client, the primary care provider should be informed of the client's request. The client doesn't need an attorney to view her chart. She also doesn't need to wait until after discharge to view it.
39. 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 1 hour
B. Never
C. If a voluntary client wants to leave against medical advice
D. When a minor child is out of control
Rationale: The primary physician in charge of a client's care must write an order for the restraint within 1 hour. 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.
40. The nurse is caring for a client diagnosed with body dysmorphic disorder. When the client verbalizes disapproval of her physical features, the nurse should:
A. encourage verbalizations about fears and stressful life situations.
B. agree with the client because she feels a specific physical feature is awful.
C. ignore the comment and talk about less threatening issues.
D. compliment the client on her appearance.
Rationale: Encouraging the client to discuss stressful life situations helps focus on the underlying issues. The client's preoccupation with a specific physical feature is a means of not coping with life. Ignoring the client or complimenting the client won't be helpful. She won't be able to accept the compliment. Agreeing with her strengthens her problem.
41. In a group therapy setting, one member is very demanding, repeatedly interrupting others, and taking most of the group time. The nurse's best response would be:
A. "Will you briefly summarize your point because others need time also?"
B. "Your behavior is obnoxious and drains the group."
C. To ignore the behavior and allow him to vent.
D. "I'm so frustrated with your behavior."
Rationale: Option A redirects the client to focus his comments and allows him to make his point. Option B is judgmental, and option C doesn't help facilitate communication. Option D focuses more on the nurse than on the client's need.
42. The nurse must assess judgment to determine a client's mental status. Which test best accomplishes this?
A. Interpreting proverbs
B. Spelling words backward
C. Counting by serial sevens
D. Discussing hypothetical ethical situations
Rationale: Hypothetical ethical situations — such as "What would you do if you found a wallet containing credit cards and identification?" — are used to test judgment. Proverb interpretation tests thinking. Spelling words backward and counting by serial sevens test concentration.
43. Which of the following statements describes how elderly clients react to medications?
A. At risk for increased adverse effects
B. Tolerate medication better because they're less active
C. Metabolize medications quickly
D. Need higher doses to respond to the same medication
Rationale: As individuals become older, their livers metabolize drugs at a slower rate. Cumulative effects can occur and increase the risk of adverse effects. Elderly clients typically need lower doses not higher. Level of activity typically doesn't affect a person's reaction to medication.
44. Which of the following indications is the primary use for electroconvulsive therapy (ECT)?
A. Severe agitation
B. Antisocial behavior
C. Noncompliance with treatment
D. Major depression with psychotic features
Rationale: ECT is indicated for depression. ECT isn't indicated for severe agitation, antisocial behavior, or treatment noncompliance.
45. Conditions necessary for the development of a positive sense of self-esteem include:
A. consistent limits.
B. critical environment.
C. inconsistent boundaries.
D. physical discipline.
Rationale: A structured lifestyle demonstrates acceptance and caring and provides a sense of security. A critical environment erodes a person's esteem. Inconsistent boundaries lead to feelings of insecurity and lack of concern. Physical discipline can decrease self-esteem.
