mental health nursing practice test 10

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Mental Health Nursing Practice Test 10

1. Flumazenil (Romazicon) has been ordered for a client who has overdosed on oxazepam

(Serax). Before administering the medication, the nurse should be prepared for which common

adverse effect?

A. Seizures

B. Shivering

C. Anxiety

D. Chest pain

2. The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a

client diagnosed with bulimia is to:

A. avoid shopping for large amounts of food.

B. control eating impulses.

C. identify anxiety-causing situations.

D. eat only three meals per day.

3. A client who's at high risk for suicide needs close supervision. To best ensure the client's

safety, the nurse should:

A. check the client frequently at irregular intervals throughout the night.

B. assure the client that the nurse will hold in confidence anything the client says.

C. repeatedly discuss previous suicide attempts with the client.

D. disregard decreased communication by the client because this is common in suicidal clients.

4. Which of the following drugs should the nurse prepare to administer to a client with a toxic

acetaminophen (Tylenol) level?

A. deferoxamine mesylate (Desferal)

B. succimer (Chemet)

C. flumazenil (Romazicon)

D. acetylcysteine (Mucomyst)

5. A client is admitted to the substance abuse unit for alcohol detoxification. Which of the

following medications is the nurse most likely to administer to reduce the symptoms of alcohol

withdrawal?

A. naloxone (Narcan)

B. haloperidol (Haldol)


C. magnesium sulfate

D. chlordiazepoxide (Librium)

6. During postprandial monitoring, a client with bulimia nervosa tells the nurse, "You can sit

with me, but you're just wasting your time. After you sat with me yesterday, I was still able to

purge. Today, my

goal is to do it twice." What is the nurse's best response?

A. "I trust you not to purge."

B. "How are you purging and when do you do it?"

C. "Don't worry. I won't allow you to purge today."

D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you

eat."

7. A client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, "It

felt so wonderful to get high." Which of the following is the most appropriate response?

A. "If you continue to talk like that, I'm going to stop speaking to you."

B. "You told me you got fired from your last job for missing too many days after taking drugs all

night."

C. "Tell me more about how it felt to get high."

D. "Don't you know it's illegal to use drugs?"

8. For a client with anorexia nervosa, which goal takes the highest priority?

A. The client will establish adequate daily nutritional intake.

B. The client will make a contract with the nurse that sets a target weight.

C. The client will identify self-perceptions about body size as unrealistic.

D. The client will verbalize the possible physiological consequences of self-starvation.

9. When interviewing the parents of an injured child, which of the following is the strongest

indicator that child abuse may be a problem?

A. The injury isn't consistent with the history or the child's age.

B. The mother and father tell different stories regarding what happened.

C. The family is poor.

D. The parents are argumentative and demanding with emergency department personnel.

10. For a client with anorexia nervosa, the nurse plans to include the parents in therapy sessions

along with the client. What fact should the nurse remember to be typical of parents of clients

with anorexia


nervosa?

A. They tend to overprotect their children.

B. They usually have a history of substance abuse.

C. They maintain emotional distance from their children.

D. They alternate between loving and rejecting their children.

11. In the emergency department, a client with facial lacerations states that her husband beat her

with a shoe. After the health care team repairs her lacerations, she waits to be seen by the crisis

intake

nurse, who will evaluate the continued threat of violence. Suddenly the client's husband arrives,

shouting that he wants to "finish the job." What is the first priority of the health care worker who

witnesses this scene?

A. Remaining with the client and staying calm

B. Calling a security guard and another staff member for assistance

C. Telling the client's husband that he must leave at once

D. Determining why the husband feels so angry

12. The nurse is caring for a client with bulimia. Strict management of dietary intake is

necessary. Which intervention is also important?

A. Fill out the client's menu and make sure she eats at least half of what is on her tray.

B. Let the client eat her meals in private. Then engage her in social activities for at least 2 hours

after each meal.

C. Let the client choose her own food. If she eats everything she orders, then stay with her for 1

hour after each meal.

D. Let the client eat food brought in by the family if she chooses, but she should keep a strict

calorie count.

13. The nurse is assigned to care for a suicidal client. Initially, which is the nurse's highest care

priority?

A. Assessing the client's home environment and relationships outside the hospital

B. Exploring the nurse's own feelings about suicide

C. Discussing the future with the client

D. Referring the client to a clergyperson to discuss the moral implications of suicide

14. A client with anorexia nervosa tells the nurse, "When I look in the mirror, I hate what I see. I

look so fat and ugly." Which strategy should the nurse use to deal with the client's distorted

perceptions and

feelings?


A. Avoid discussing the client's perceptions and feelings.

B. Focus discussions on food and weight.

C. Avoid discussing unrealistic cultural standards regarding weight.

D. Provide objective data and feedback regarding the client's weight and attractiveness.

15. The nurse is caring for a client being treated for alcoholism. Before initiating therapy with

disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of

the following

products?

A. Carbonated beverages

B. Aftershave lotion

C. Toothpaste

D. Cheese

16. The nurse is developing a plan of care for a client with anorexia nervosa. Which action

should the nurse include in the plan?

A. Restrict visits with the family until the client begins to eat.

B. Provide privacy during meals.

C. Set up a strict eating plan for the client.

D. Encourage the client to exercise, which will reduce her anxiety.

17. Victims of domestic violence should be assessed for what important information?

A. Reasons they stay in the abusive relationship (for example, lack of financial autonomy and

isolation)

B. Readiness to leave the perpetrator and knowledge of resources

C. Use of drugs or alcohol

D. History of previous victimization

18. A client is hospitalized with fractures of the right femur and right humerus sustained in a

motorcycle accident. Police suspect the client was intoxicated at the time of the accident.

Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dl). The client later admits to

drinking heavily for years. During hospitalization, the client periodically complains of tingling

and numbness in the hands and feet. The nurse realizes that these symptoms probably result

from:

A. acetate accumulation.

B. thiamine deficiency.

C. triglyceride buildup.

D. a below-normal serum potassium level


19. A parent brings a preschooler to the emergency department for treatment of a dislocated

shoulder, which allegedly happened when the child fell down the stairs. Which action should

make the nurse

suspect that the child was abused?

A. The child cries uncontrollably throughout the examination.

B. The child pulls away from contact with the physician.

C. The child doesn't cry when the shoulder is examined.

D. The child doesn't make eye contact with the nurse.

20. When planning care for a client who has ingested phencyclidine (PCP), which of the

following is the highest priority?

A. Client's physical needs

B. Client's safety needs

C. Client's psychosocial needs

D. Client's medical needs

21. Which outcome criteria would be appropriate for a child diagnosed with oppositional defiant

disorder?

A. Accept responsibility for own behaviors.

B. Be able to verbalize own needs and assert rights.

C. Set firm and consistent limits with the client.

D. Allow the child to establish his own limits and boundaries.

22. A client is found sitting on the floor of the bathroom in the day treatment clinic with

moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at her

bleeding wrists while

staff members call for an ambulance. How should the nurse approach her initially?

A. Enter the room quietly and move beside her to assess her injuries.

B. Call for staff back-up before entering the room and restraining her.

C. Move as much glass away from her as possible and sit next to her quietly.

D. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the

nurse is here to help her.

23. A client with anorexia nervosa describes herself as "a whale." However, the nurse's

assessment reveals that the client is 5′ 8" (1.7 m) tall and weighs only 90 lb (40.8 kg).

Considering the client's


unrealistic body image, which intervention should be included in the plan of care?

A. Asking the client to compare her figure with magazine photographs of women her age

B. Assigning the client to group therapy in which participants provide realistic feedback about

her weight

C. Confronting the client about her actual appearance during one-on-one sessions, scheduled

during each shift

D. Telling the client of the nurse's concern for her health and desire to help her make decisions to

keep her healthy

24. Eighteen hours after undergoing an emergency appendectomy, a client with a reported

history of social drinking displays these vital signs: temperature, 101.6° F (38.7° C); heart rate,

126 beats/minute;

respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm Hg. The client exhibits gross

hand tremors and is screaming for someone to kill the bugs in the bed. The nurse should suspect:

A. a postoperative infection.

B. alcohol withdrawal.

C. acute sepsis.

D. pneumonia.

25. Clonidine (Catapres) can be used to treat conditions other than hypertension. For which of

the following conditions might the drug be administered?

A. Phencyclidine (PCP) intoxication

B. Alcohol withdrawal

C. Opiate withdrawal

D. Cocaine withdrawal

26. One of the goals for a client with anorexia nervosa is that the client will demonstrate

increased individual coping by responding to stress in constructive ways. Which of the following

actions is the best

indicator that the client is working toward meeting the goal?

A. The client drinks 4 L of fluid per day.

B. The client paces around the unit most of the day.

C. The client keeps a journal and discusses it with the nurse.

D. The client talks almost constantly with friends by telephone.

27. The nurse in the substance abuse unit is trying to encourage a client to attend Alcoholics

Anonymous meetings. When the client asks the nurse what he must do to become a member, the

nurse should


respond:

A. "You must first stop drinking."

B. "Your physician must refer you to this program."

C. "Admit you're powerless over alcohol and that you need help."

D. "You must bring along a friend who will support you."

28. An attorney who throws books and furniture around the office after losing a case is referred

to the psychiatric nurse in the law firm's employee assistance program. The nurse knows that the

client's behavior most likely represents the use of which defense mechanism?

A. Regression

B. Projection

C. Reaction-formation

D. Intellectualization

29. After completing chemical detoxification and a 12-step program to treat crack addiction, a

client is being prepared for discharge. Which remark by the client indicates a realistic view of the

future?

A. "I'm never going to use crack again."

B. "I know what I have to do. I have to limit my crack use."

C. "I'm going to take 1 day at a time. I'm not making any promises."

D. "I will substitue crack for something else"

30. The nurse is assessing a client on admission to the chemical dependency unit for alcohol

detoxification. When the nurse asks about alcohol use, this client is most likely to:

A. accurately describe the amount consumed.

B. underestimate the amount consumed.

C. overestimate the amount consumed.

D. deny any consumption of alcohol.

31. The nurse is assessing a 15-year-old female who's being admitted for treatment of anorexia

nervosa. Which clinical manifestation is the nurse most likely to find?

A. Tachycardia

B. Warm, flushed extremities

C. Parotid gland tenderness

D. Coarse hair growth


32. A 38-year-old client is admitted for alcohol withdrawal. The most common early sign or

symptom that this client is likely to experience is:

A. impending coma.

B. manipulating behavior.

C. suppression.

D. perceptual disorders.

33. The nurse is caring for an adolescent female who reports amenorrhea, weight loss, and

depression. Which additional assessment finding would suggest that the woman has an eating

disorder?

A. Wearing tight-fitting clothing

B. Increased blood pressure

C. Oily skin

D. Excessive and ritualized exercise

34. A client with a history of polysubstance abuse is admitted to the facility. She complains of

nausea and vomiting 24 hours after admission. The nurse assesses the client and notes

piloerection,

pupillary dilation, and lacrimation. The nurse suspects that the client is going through which of

the following withdrawals?

A. Alcohol withdrawal

B. Cannibis withdrawal

C. Cocaine withdrawal

D. Opioid withdrawal

35. A client is admitted to the psychiatric unit with a diagnosis of anorexia nervosa. Although

she is 5′ 8" (1.7 m) tall and weighs only 103 lb (46.7 kg), she talks incessantly about how fat she

is. Which

measure should the nurse take first when caring for this client?

A. Teach the client about nutrition, calories, and a balanced diet.

B. Establish a trusting relationship with the client.

C. Discuss cultural stereotypes regarding thinness and attractiveness.

D. Explore the reasons why the client doesn't eat.

36. A client is admitted for an overdose of amphetamines. When assessing this client, the nurse

should expect to see:


A. tension and irritability.

B. slow pulse.

C. hypotension.

D. constipation.

37. Which of the following drugs may be abused because of tolerance and physiologic

dependence.

A. lithium (Lithobid) and divalproex (Depakote).

B. verapamil (Calan) and chlorpromazine (Thorazine)

C. alprazolam (Xanax) and phenobarbital (Luminal)

D. clozapine (Clozaril) and amitriptyline (Elavil)

38. Which of the following groups are considered to be at highest risk for suicide?

A. Adolescents, men over age 45, and persons who have made previous suicide attempts

B. Teachers, divorced persons, and substance abusers

C. Alcohol abusers, widows, and young married men

D. Depressed persons, physicians, and persons living in rural areas

39. Tourette syndrome is characterized by the presence of multiple motor and vocal tics. A vocal

tic that involves repeating one's own sounds or words is known as:

A. echolalia.

B. palilalia.

C. apraxia.

D. aphonia.

40. A client is admitted to the psychiatric unit with a diagnosis of borderline personality disorder.

The nurse expects the assessment to

reveal:

A. unpredictable behavior and intense interpersonal relationships.

B. inability to function as a responsible parent.

C. somatic symptoms.

D. coldness, detachment, and lack of tender feelings.

41. A client with disorganized type schizophrenia has been hospitalized for the past 2 years on a

unit for chronic mentally ill clients. The client's behavior is labile and fluctuates from

childishness

and incoherence to loud yelling to slow but appropriate interaction. The client needs assistance


with all activities of daily living. Which behavior is characteristic of disorganized type

schizophrenia?

A. Extreme social impairment

B. Suspicious delusions

C. Waxy flexibility

D. Elevated affect

42. The nurse is providing care for a female client with a history of schizophrenia who's

experiencing hallucinations. The physician orders 200 mg of haloperidol (Haldol) orally or I.M.

every 4 hours as needed.

What is the nurse's best action?

A. Administer the haloperidol orally if the client agrees to take it.

B. Call the physician to clarify whether the haloperidol should be given orally or I.M.

C. Call the physician to clarify the order because the dosage is too high.

D. Withhold haloperidol because it may worsen hallucinations.

43. A client receiving haloperidol (Haldol) complains of a stiff jaw and difficulty swallowing.

The nurse's first action is to:

A. reassure the client and administer as needed lorazepam (Ativan) I.M.

B. administer as needed dose of benztropine (Cogentin) I.M. as ordered.

C. administer as needed dose of benztropine (Cogentin) by mouth as ordered.

D. administer as needed dose of haloperidol (Haldol) by mouth.

44. A 24-year-old client is experiencing an acute schizophrenic episode. He has vivid

hallucinations that are making him agitated. The nurse's best response at this time would be to:

A. take the client's vital signs.

B. explore the content of the hallucinations.

C. tell him his fear is unrealistic.

D. engage the client in reality-oriented activities.

45. Which medication can control the extrapyramidal effects associated with antipsychotic

agents?

A. perphenazine (Trilafon)

B. doxepin (Sinequan)

C. amantadine (Symmetrel)

D. clorazepate (Tranxene)


46. A client with paranoid schizophrenia has been experiencing auditory hallucinations for many

years. One approach that has proven to be effective for hallucinating clients is to:

A. take an as-needed dose of psychotropic medication whenever they hear voices.

B. practice saying "Go away" or "Stop" when they hear voices.

C. sing loudly to drown out the voices and provide a distraction.

D. go to their room until the voices go away.

47. A dystonic reaction can be caused by which of the following medications?

A. diazepam (Valium)

B. haloperidol (Haldol)

C. amitriptyline (Elavil)

D. clonazepam (Klonopin)

48. While pacing in the hall, a client with paranoid schizophrenia runs to the nurse and says,

"Why are you poisoning me? I know you work for central thought control! You can keep my

thoughts. Give me back my soul!" How should the nurse respond during the early stage of the

therapeutic process?

A. "I'm a nurse. I'm not poisoning you. It's against the nursing code of ethics."

B. "I'm a nurse, and you're a client in the hospital. I'm not going to harm you."

C. "I'm not poisoning you. And how could I possibly steal your soul?"

D. "I sense anger. Are you feeling angry today?"

49. A client is admitted to the inpatient unit of the mental health center with a diagnosis of

paranoid schizophrenia. He's shouting that the government of France is trying to assassinate him.

Which of the

following responses is most appropriate?

A. "I think you're wrong. France is a friendly country and an ally of the United States. Their

government wouldn't try to kill you."

B. "I find it hard to believe that a foreign government or anyone else is trying to hurt you. You

must feel frightened by this."

C. "You're wrong. Nobody is trying to kill you."

D. "A foreign government is trying to kill you? Please tell me more about it."


Answer and Rationale Test 10

1. A. Seizures

Rationale: Seizures are the most common serious adverse effect of using flumazenil to reverse

benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic

antidepressant and benzodiazepine overdose. Less common adverse effects include shivering,

anxiety, and chest pain.

2. C. identify anxiety-causing situations.

Rationale: Bulimic behavior is generally a maladaptive coping response to stress and underlying

issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior

and then learn new ways of coping with the anxiety. Controlling shopping for large amounts of

food isn't a goal early in treatment. Managing eating impulses and replacing them with adaptive

coping mechanisms can be integrated into the plan of care after initially addressing stress and

underlying issues. Eating three meals per day isn't a realistic goal early in treatment.

3. A. check the client frequently at irregular intervals throughout the night.

Rationale: Checking the client frequently but at irregular intervals prevents the client from

predicting when observation will take place and altering behavior in a misleading way at these

times. Option B may encourage the client to try to manipulate the nurse or seek attention for

having a secret suicide plan. Option C may reinforce suicidal ideas. Decreased communication is

a sign of withdrawal that may indicate the client has decided to commit suicide; the nurse

shouldn't disregard it (option D

4.D. acetylcysteine (Mucomyst)

Rationale: The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion of

toxic metabolites to nontoxic metabolites. Deferoxamine mesylate is the antidote for iron

intoxication. Succimer is an antidote for lead poisoning. Flumazenil reverses the sedative effects

of benzodiazepines.

5. D. chlordiazepoxide (Librium)

Rationale: Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of

alcohol withdrawal. Haloperidol (Haldol) may be given to treat clients with psychosis, severe

agitation, or delirium. Naloxone (Narcan) is administered for narcotic overdose. Magnesium

sulfate and other anticonvulsant medications are only administered to treat seizures if they occur

during withdrawal.

6. D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes

after you eat."

Rationale: This response acknowledges that the client is testing limits and that the nurse is

setting them by performing postprandial monitoring to prevent self-induced emesis. Clients with


bulimia nervosa need to feel in control of the diet because they feel they lack control over all

other aspects of their lives. Because their therapeutic relationships with caregivers are less

important than their need to purge, they don't fear betraying the nurse's trust by engaging in the

activity. They commonly plot purging and rarely share their secrets about it. An authoritarian or

challenging response may trigger a power struggle between the nurse and client.

7. B. "You told me you got fired from your last job for missing too many days after taking

drugs all night."

Rationale: Confronting the client with the consequences of substance abuse helps to break

through denial. Making threats (option A) isn't an effective way to promote self-disclosure or

establish a rapport with the client. Although the nurse should encourage the client to discuss

feelings, the discussion should focus on how the client felt before, not during, an episode of

substance abuse (option C). Encouraging elaboration about his experience while getting high

may reinforce the abusive behavior. The client undoubtedly is aware that drug use is illegal; a

reminder to this effect (option D) is unlikely to alter behavior.

8. A. The client will establish adequate daily nutritional intake.

Rationale: According to Maslow's hierarchy of needs, all humans need to meet basic

physiological needs first. Because a client with anorexia nervosa eats little or nothing, the nurse

must first plan to help the client meet this basic, immediate physiological need. The nurse may

give lesser priority to goals that address long-term plans (as in option B), self-perception (as in

option C), and potential complications (as in option D).

9. A. The injury isn't consistent with the history or the child's age.

Rationale: When the child's injuries are inconsistent with the history given or impossible because

of the child's age and developmental stage, the emergency department nurse should be suspicious

that child abuse is occurring. The parents may tell different stories because their perception may

be different regarding what happened. If they change their story when different health care

workers ask the same question, this is a clue that child abuse may be a problem. Child abuse

occurs in all socioeconomic groups. Parents may argue and be demanding because of the stress

of having an injured child.

10.A. They tend to overprotect their children.

Rationale: Clients with anorexia nervosa typically come from a family with parents who are

controlling and overprotective. These clients use eating to gain control of an aspect of their lives.

The characteristics described in options B, C, and D aren't typical of parents of children with

anorexia.

11. B. Calling a security guard and another staff member for assistance

Rationale: The health care worker who witnesses this scene must take precautions to ensure


personal as well as client safety, but shouldn't attempt to manage a physically aggressive person

alone. Therefore, the first priority is to call a security guard and another staff member. After

doing this, the health care worker should inform the husband what is expected, speaking in

concise statements and maintaining a firm but calm demeanor. This approach makes it clear that

the health care worker is in control and may diffuse the situation until the security guard arrives.

Telling the husband to leave would probably be

ineffective because of his agitated and irrational state. Exploring his anger doesn't take

precedence over safeguarding the client and staff.

12. C. Let the client choose her own food. If she eats everything she orders, then stay with

her for 1 hour after each meal.

Rationale: Allowing the client to select her own food from the menu will help her feel some

sense of control. She must then eat 100% of what she selected. Remaining with the client for at

least 1 hour after eating will prevent purging. Bulimic clients should only be allowed to eat food

provided by the dietary department.

13. B. Exploring the nurse's own feelings about suicide

Rationale: The nurse's values, beliefs, and attitudes toward self-destructive behavior influence

responses to a suicidal client; such responses set the overall mood for the nurse-client

relationship. Therefore, the nurse initially must explore personal feelings about suicide to avoid

conveying negative feelings to the client. Assessment of the client's home environment and

relationships may reveal the need for family therapy; however, conducting such an assessment

isn't

a nursing priority. Discussing the future and providing anticipatory guidance can help the client

prepare for future stress, but this isn't a priority. Referring the client to a clergyperson may

increase the client's trust or alleviate guilt; however, it isn't the highest priority.

14. D. Provide objective data and feedback regarding the client's weight and attractiveness.

Rationale: By focusing on reality, this strategy may help the client develop a more realistic body

image and gain self-esteem. Option A is inappropriate because discussing the client's perceptions

and feeling wouldn't help her to identify, accept, and work through them. Focusing discussions

on food and weight would give the client attention for not eating, making option B incorrect.

Option C is inappropriate because recognizing unrealistic cultural standards wouldn't help the

client establish more realistic weight goals.

15. B. Aftershave lotion

Rationale: Disulfiram may be given to clients with chronic alcohol abuse who wish to curb

impulse drinking. Disulfiram works by blocking the oxidation of alcohol, inhibiting the

conversion of acetaldehyde to acetate. As acetaldehyde builds up in the blood, the client

experiences noxious and uncomfortable symptoms. Even alcohol rubbed onto the skin can


produce a reaction. The client receiving disulfiram must be taught to read ingredient labels

carefully to avoid products containing alcohol such as aftershave lotions. Carbonated beverages,

toothpaste, and cheese don't contain alcohol and don't need to be avoided by the

client.

16. C. Set up a strict eating plan for the client.

Rationale: Establishing a consistent eating plan and monitoring the client's weight are important

for this disorder. The family should be included in the client's care. The client should be

monitored during meals — not given privacy. Exercise must be limited and supervised.

17. B. Readiness to leave the perpetrator and knowledge of resources

Rationale: Victims of domestic violence must be assessed for their readiness to leave the

perpetrator and their knowledge of the resources available to them. Nurses can then provide the

victims with information and options to enable them to leave when they are ready. The reasons

they stay in the relationship are complex and can be explored at a later time. The use of drugs or

alcohol is irrelevant. There is no evidence to suggest that previous victimization results in a

person's seeking or causing abusive relationships.

18.B. thiamine deficiency.

Rationale: Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis,

which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and

excessive alcohol intake. Treatment includes reducing alcohol intake, correcting nutritional

deficiencies through diet and vitamin supplements, and preventing such residual disabilities as

foot and wrist drop. Acetate accumulation, triglyceride buildup, and a below-normal serum

potassium level are unrelated to the client's symptoms.

19. C. The child doesn't cry when the shoulder is examined.

Rationale: A characteristic behavior of abused children is lack of crying when they undergo a

painful procedure or are examined by a health care professional. Therefore, the nurse should

suspect child abuse. Crying throughout the examination, pulling away from the physician, and

not making eye contact with the nurse are normal behaviors for preschoolers.

20. B. Client's safety needs

Rationale: The highest priority for a client who has ingested PCP is meeting safety needs of the

client as well as the staff. Drug effects are unpredictable and prolonged, and the client may lose

control easily. After safety needs have been met, the client's physical, psychosocial, and medical

needs can be met.

21. A. Accept responsibility for own behaviors.

Rationale: Children with oppositional defiant disorder frequently violate the rights of others.


They are defiant, disobedient, and blame others for their actions. Accountability for their actions

would demonstrate progress for the oppositional child. Options C and D aren't outcome criteria

but interventions. Option B is incorrect as the oppositional child usually focuses on his own

needs.

22. D. Approach her slowly while speaking in a calm voice, calling her name, and telling

her that the nurse is here to help her.

Rationale: Ensuring the safety of the client and the nurse is the priority at this time. Therefore,

the nurse should approach the client cautiously while calling her name and talking to her in a

calm, confident manner. The nurse should keep in mind that the client shouldn't be startled or

overwhelmed. After explaining that the nurse is there to help, the nurse should observe the

client's response carefully. If the client shows signs of agitation or confusion or poses a threat,

the nurse should retreat and request assistance. The nurse shouldn't attempt to sit next to the

client or examine injuries without first announcing the

nurse's presence and assessing the dangers of the situation.

23. D. Telling the client of the nurse's concern for her health and desire to help her make

decisions to keep her healthy

Rationale: A client with anorexia nervosa has an unrealistic body image that causes consumption

of little or no food. Therefore, the client needs assistance with making decisions about health.

Instead of protecting the client's health, options A, B, and C may serve to make the client

defensive and more entrenched in her unrealistic body image.

24. B. alcohol withdrawal.

Rationale: The client's vital signs and hallucinations suggest delirium tremens or alcohol

withdrawal syndrome. Although infection, acute sepsis, and pneumonia may arise as

postoperative complications, they wouldn't cause this client's signs and symptoms and typically

would occur later in the postoperative course.

25. C. Opiate withdrawal

Rationale: Clonidine is used as adjunctive therapy in opiate withdrawal. Benzodiazepines, such

as chlordiazepoxide (Librium), and neuropleptic agents, such as haloperidol, are used to treat

alcohol withdrawal. Benzodiazepines and neuropleptic agents are typically used to treat PCP

intoxication. Antidepressants and medications with dopaminergic activity in the brain, such as

fluoxotine (Prozac), are used to treat cocaine withdrawal.

26.C. The client keeps a journal and discusses it with the nurse.

Rationale: The client is moving toward meeting the goal because recording and discussing

feelings is a constructive way to manage stress. Although physical activity can reduce stress, the

anorexic client is more likely to use pacing to burn calories and lose weight. Although talks with


friends can decrease stress, constant talking is more likely a way of avoiding dealing with

problems. Increased fluid intake may be an attempt by the client to curb her appetite and

artificially increase her weight.

27. C. "Admit you're powerless over alcohol and that you need help."

Rationale: The first of the "Twelve Steps of Alcoholics Anonymous" is admitting that an

individual is powerless over alcohol and that life has become unmanageable. Although

Alcoholics Anonymous promotes total abstinence, a client will still be accepted if he drinks. A

physician referral isn't necessary to join. New members are assigned a support person who may

be called upon when the client has the urge to drink.

28. A. Regression

Rationale: An adult who throws temper tantrums, such as this one, is displaying regressive

behavior, or behavior that is appropriate at a younger age. In projection, the client blames

someone or something other than the source. In reaction formation, the client acts in opposition

to his feelings. In intellectualization, the client overuses rational explanations or abstract thinking

to decrease the significance of a feeling or event.

29. C. "I'm going to take 1 day at a time. I'm not making any promises."

Rationale: Twelve-step programs focus on recovery 1 day at a time.Such programs discourage

people from claiming that they will never again use a substance, because relapse is common. The

belief that one may use a limited amount of an abused substance indicates denial. Substituting

one abused substance for another predisposes the client to cross-addiction.

30. B. underestimate the amount consumed.

Rationale: Most people who abuse substances underestimate their consumption in an attempt to

conform to social norms or protect themselves. Few accurately describe or overestimate

consumption; some may deny it. Therefore, on admission, quantitative and qualitative toxicology

screens are done to validate information obtained from the client.

31. C. Parotid gland tenderness

Rationale: Frequent vomiting causes tenderness and swelling of the parotid glands. The reduced

metabolism that occurs with severe weight loss produces bradycardia and cold extremities. Soft,

downlike hair (called lanugo) may cover the extremities, shoulders, and face of an anorexic

client.

32. D. perceptual disorders.

Rationale: Perceptual disorders, especially frightening visual hallucinations, are very common

with alcohol withdrawal. Coma isn't an immediate consequence. Manipulative behaviors are part

of the alcoholic client's personality but aren't signs of alcohol withdrawal. Suppression is a


conscious effort to conceal unacceptable thoughts, feelings, impulses, or acts and serves as a

coping mechanism for most alcoholics.

33.D. Excessive and ritualized exercise

Rationale: A client with an eating disorder will normally exercise to excess in an effort to burn as

many calories as possible. The client will usually wear loose-fitting clothing to hide what she

considers to be a fat body. Skin and nails become dry and brittle and blood pressure and body

temperature drop from excessive weight loss.

34. D. Opioid withdrawal

Rationale: The symptoms listed are specific to opioid withdrawal. Alcohol withdrawal would

show elevated vital signs. There is no real withdrawal from cannibis. Symptoms of cocaine

withdrawal include depression, anxiety, and agitation.

35. B. Establish a trusting relationship with the client.

Rationale: A client with an eating disorder may be secretive and unwilling to admit that a

problem exists. Therefore, the nurse first must establish a trusting relationship to elicit the

client's feelings and thoughts. The anorexic client may spend long hours discussing nutrition or

handling and preparing food in an effort to stall or avoid eating food; the nurse shouldn't

reinforce her preoccupation with food, as in option A. Although cultural stereotypes may play a

prominent

role in anorexia nervosa, discussing these factors isn't the first action the nurse should take.

Exploring the reasons why the client doesn't eat would increase her emotional investment in food

and eating.

36. A. tension and irritability.

Rationale: An amphetamine is a nervous system stimulant that is subject to abuse because of its

ability to produce wakefulness and euphoria. An overdose increases tension and irritability.

Options B and C are incorrect because amphetamines stimulate norepinephrine, which increases

the heart rate and blood flow. Diarrhea is a common adverse effect, so option D is incorrect.

37. C. alprazolam (Xanax) and phenobarbital (Luminal)

Rationale: Both benzodiazepines, such as alprazolam, and barbiturates, such as phenobarbital,

are addictive, controlled substances. All the other drugs listed aren't addictive substances.

38. A. Adolescents, men over age 45, and persons who have made previous suicide attempts

Rationale: Studies of those who commit suicide reveal the following high-risk groups:

adolescents; men over age 45; persons who have made previous suicide attempts; divorced,

widowed, and separated persons; professionals, such as physicians, dentists, and attorneys;

students; unemployed persons; persons who are depressed, delusional, or hallucinating; alcohol


or substance abusers; and persons who live in urban areas. Although more women attempt

suicide than

men, they typically choose less lethal means and therefore are less likely to succeed in their

attempts.

39. B. palilalia.

Rationale: Palilalia is defined as the repetition of sounds and words. Echolalia is the act of

repeating the words of others. Apraxia is the inability to carry out motor activities, and aphonia is

the inability to speak

40. A. unpredictable behavior and intense interpersonal relationships.

Rationale: 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.

41. A. Extreme social impairment

Rationale: Disorganized type schizophrenia (formerly called hebephrenia) is characterized by

extreme social impairment, marked inappropriate affect, silliness, grimacing, posturing, and

fragmented delusions and hallucinations. A client with a paranoid disorder typically exhibits

suspicious delusions, such as a belief that evil forces are after him. Waxy flexibility, a condition

in which the client's limbs remain fixed in uncomfortable positions for long periods,

characterizes

catatonic schizophrenia. Elevated affect is associated withschizoaffective disorder.

42. C. Call the physician to clarify the order because the dosage is too high.

Rationale: The dosage is too high (normal dosage ranges from 5 to 10 mg daily). Options A and

B may lead to an overdose. Option D is incorrect because haloperidol helps with symptoms of

hallucinations.

43. B. administer as needed dose of benztropine (Cogentin) I.M. as ordered.

Rationale: The client is most likely suffering from muscle rigidity due to haloperidol. I.M.

benztropine should be administered to prevent asphyxia or aspiration. Lorazepam treats anxiety,

not extrapyramidal effects. Another dose of haloperidol would increase the severity of the

reaction.

44. B. explore the content of the hallucinations.


Rationale: Exploring the content of the hallucinations will help the nurse understand the client's

perspective on the situation. The client shouldn't be touched, such as in taking vital signs,

without telling him exactly what is going to happen. Debating with the client about his emotions

isn't therapeutic. When the client is calm, engage him in reality-based activities.

45. C. amantadine (Symmetrel)

Rationale: Amantadine 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.

46. B. practice saying "Go away" or "Stop" when they hear voices.

Rationale: Researchers have found that some clients can learn to control bothersome

hallucinations by telling the voices to go away or stop. Taking an as needed dose of psychotropic

medication whenever the voices arise may lead to overmedication and put the client at risk for

adverse effects. Because the voices aren't likely to go away permanently, the client must learn to

deal with the hallucinations without relying on drugs. Although distraction is helpful, singing

loudly may upset other clients and would be socially unacceptable after the client is discharged.

Hallucinations are most bothersome in a quiet

environment when the client is alone, so sending the client to his room would increase, rather

than decrease, the hallucinations.

47. B. haloperidol (Haldol)

Rationale: Haloperidol is a phenothiazine and is capable of causing dystonic reactions. Diazepam

and clonazepam are benzodiazepines, and amitriptyline is a tricyclic antidepressant.

Benzodiazepines don't cause dystonic reactions; however, they can cause drowsiness, lethargy,

and hypotension. Tricyclic antidepressants rarely cause severe dystonic reactions; however, they

can cause a decreased level of consciousness, tachycardia, dry mouth, and dilated pupils.

48. B. "I'm a nurse, and you're a client in the hospital. I'm not going to harm you."

Rationale: The nurse should directly orient a delusional client to reality, especially to place and

person. Options A and C may encourage further delusions by denying poisoning and offering

information related to the delusion. Validating the client's feelings, as in option D, occurs during

a later stage in the therapeutic process.

49. B. "I find it hard to believe that a foreign government or anyone else is trying to hurt


you. You must feel frightened by this."

Rationale: Responses should focus on reality while acknowledging the client's feelings. Arguing

with the client or denying his belief isn't therapeutic. Arguing can also inhibit development of a

trusting relationship. Continuing to talk about delusions may aggravate the psychosis. Asking the

client if a foreign government is trying to kill him may increase his anxiety level and can reinforce

his delusions.

mental health nursing practice test 10

Education

client whos

following drugs

child abuse

bulimia nervosa

following medications

substance abuse unit

treatment of substance

flumazenil romazicon