A nurse decides to use the CAGE screening questionnaire with a client admitted for substance
abuse. What is the client abusing?
Alcohol
Barbiturates
Hallucinogens
Multiple drugs
A nurse is caring for a hyperactive, manic client who exhibits flight of ideas and is not eating.
What may be the reason why the client is not eating?
Feeling undeserving of the food
Too busy to take the time to eat
Wishes to avoid others in the dining room
Believes that there is no need for food at this time
What childhood problem has legal as well as emotional aspects and cannot be ignored?
School phobia
Fear of animals
Fear of monsters
Sleep disturbances
A client is admitted to the psychiatric hospital after many self-inflicted nonlethal injuries over the
preceding month. Of which level of suicidal behavior is the client's behavior reflective?
Threats
Ideation
Gestures
Attempts
A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive
disorder (OCD). Before providing care for this client, what should the nurse remember about
clients with OCD?
Are unaware that the ritual serves no purpose
Can alter the ritual depending on the situation
Should be prevented from performing the ritual
Do not want to repeat the ritual but feel compelled to do so
During an interview of a client with a diagnosis of bipolar I disorder, manic episode, what does
the nurse expect the client to demonstrate?
Flight of ideas
Ritualistic behaviors
Associative looseness
Auditory hallucinations
,The nurse would recognize which behavior as being characteristic of the panic phase of crisis
behavior?
Being physically immobile
Sobbing for no apparent reason
Reporting great difficulties falling asleep
Startling easily to loud noises and being touched
For which clinical indication should a nurse observe a child in whom autism is suspected?
Lack of eye contact
Crying for attention
Catatonia-like rigidity
Engaging in parallel play
A client with paralysis of the legs is found to have somatoform disorder, conversion type. What
must the nurse consider when formulating a plan of care for this client?
The illness is very real to the client and requires appropriate nursing care.
Although the client believes that there is an illness, there is no cause for concern.
There is no physiological basis for the illness; therefore only emotional care is
needed.
Nursing intervention is needed even though the nurse understands that the client is
not ill.
The nurse is assigned to work with a 20-year-old client on an inpatient unit. In assessing the
woman, the nurse notes that she is mute, does not show any type of movement, is unresponsive,
and appears unaware of her surroundings. What is the best term for the nurse to use to describe
these symptoms?
Alogia
Catatonia
Echopraxia
Affective flattening
When planning for a client's care during the detoxification phase of acute alcohol withdrawal,
what need should the nurse anticipate?
Checking on the client frequently
Keeping the client's room lights dim
Addressing the client in a loud, clear voice
Restraining the client during periods of agitation
A female client with obsessive-compulsive disorder has become immobilized by her elaborate
handwashing and walking rituals. Which feelings does the nurse recall are often the basis of
obsessive-compulsive disorder?
Anxiety and guilt
Anger and hostility
, Embarrassment and shame
Hopelessness and powerlessness
A nurse is planning care for a client with substance-induced persisting dementia resulting from
long-term alcohol use. Which nutritional problem, in addition to the effect of alcohol on brain
tissue, has contributed to substance-induced persisting dementia?
Increase in serotonin
Deficiency of thiamine
Reduction in iron intake
Malabsorption of riboflavin
A 3-year-old child is found to have a pervasive developmental disorder not otherwise specified.
What should the nurse consider most unusual for the child to demonstrate?
Interest in music
Ritualistic behavior
Attachment to odd objects
Responsiveness to the parents
During a one-on-one interaction with a client with paranoid-type schizophrenia, the client says to
the nurse, "I’ve figured out how foreign agents have infiltrated the news media. They want to
shut me up before I spill the beans." How should the nurse describe this statement when
documenting this client’s response?
Nihilistic delusion
Delusions of persecution
Delusions of control
Delusions of grandeur
A nurse is caring for a client with a somatoform disorder. What should the nurse anticipate that
this client will do?
Write down conversations to facilitate the recall of information.
Monopolize conversations about the anxiety being experienced.
Redirect the conversation with the nurse to physical symptoms.
Start a conversation asking the nurse to recommend palliative care.
A nurse, understanding the possible cause of alcohol-induced amnestic disorder, should take into
consideration that the client is probably experiencing which imbalance?
Thiamine deficiency
A reduced iron intake
An increase in serotonin
Riboflavin malabsorption
Within a few hours of alcohol withdrawal the nurse should assess the client for the presence of
what symptoms?
Irritability and tremors
abuse. What is the client abusing?
Alcohol
Barbiturates
Hallucinogens
Multiple drugs
A nurse is caring for a hyperactive, manic client who exhibits flight of ideas and is not eating.
What may be the reason why the client is not eating?
Feeling undeserving of the food
Too busy to take the time to eat
Wishes to avoid others in the dining room
Believes that there is no need for food at this time
What childhood problem has legal as well as emotional aspects and cannot be ignored?
School phobia
Fear of animals
Fear of monsters
Sleep disturbances
A client is admitted to the psychiatric hospital after many self-inflicted nonlethal injuries over the
preceding month. Of which level of suicidal behavior is the client's behavior reflective?
Threats
Ideation
Gestures
Attempts
A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive
disorder (OCD). Before providing care for this client, what should the nurse remember about
clients with OCD?
Are unaware that the ritual serves no purpose
Can alter the ritual depending on the situation
Should be prevented from performing the ritual
Do not want to repeat the ritual but feel compelled to do so
During an interview of a client with a diagnosis of bipolar I disorder, manic episode, what does
the nurse expect the client to demonstrate?
Flight of ideas
Ritualistic behaviors
Associative looseness
Auditory hallucinations
,The nurse would recognize which behavior as being characteristic of the panic phase of crisis
behavior?
Being physically immobile
Sobbing for no apparent reason
Reporting great difficulties falling asleep
Startling easily to loud noises and being touched
For which clinical indication should a nurse observe a child in whom autism is suspected?
Lack of eye contact
Crying for attention
Catatonia-like rigidity
Engaging in parallel play
A client with paralysis of the legs is found to have somatoform disorder, conversion type. What
must the nurse consider when formulating a plan of care for this client?
The illness is very real to the client and requires appropriate nursing care.
Although the client believes that there is an illness, there is no cause for concern.
There is no physiological basis for the illness; therefore only emotional care is
needed.
Nursing intervention is needed even though the nurse understands that the client is
not ill.
The nurse is assigned to work with a 20-year-old client on an inpatient unit. In assessing the
woman, the nurse notes that she is mute, does not show any type of movement, is unresponsive,
and appears unaware of her surroundings. What is the best term for the nurse to use to describe
these symptoms?
Alogia
Catatonia
Echopraxia
Affective flattening
When planning for a client's care during the detoxification phase of acute alcohol withdrawal,
what need should the nurse anticipate?
Checking on the client frequently
Keeping the client's room lights dim
Addressing the client in a loud, clear voice
Restraining the client during periods of agitation
A female client with obsessive-compulsive disorder has become immobilized by her elaborate
handwashing and walking rituals. Which feelings does the nurse recall are often the basis of
obsessive-compulsive disorder?
Anxiety and guilt
Anger and hostility
, Embarrassment and shame
Hopelessness and powerlessness
A nurse is planning care for a client with substance-induced persisting dementia resulting from
long-term alcohol use. Which nutritional problem, in addition to the effect of alcohol on brain
tissue, has contributed to substance-induced persisting dementia?
Increase in serotonin
Deficiency of thiamine
Reduction in iron intake
Malabsorption of riboflavin
A 3-year-old child is found to have a pervasive developmental disorder not otherwise specified.
What should the nurse consider most unusual for the child to demonstrate?
Interest in music
Ritualistic behavior
Attachment to odd objects
Responsiveness to the parents
During a one-on-one interaction with a client with paranoid-type schizophrenia, the client says to
the nurse, "I’ve figured out how foreign agents have infiltrated the news media. They want to
shut me up before I spill the beans." How should the nurse describe this statement when
documenting this client’s response?
Nihilistic delusion
Delusions of persecution
Delusions of control
Delusions of grandeur
A nurse is caring for a client with a somatoform disorder. What should the nurse anticipate that
this client will do?
Write down conversations to facilitate the recall of information.
Monopolize conversations about the anxiety being experienced.
Redirect the conversation with the nurse to physical symptoms.
Start a conversation asking the nurse to recommend palliative care.
A nurse, understanding the possible cause of alcohol-induced amnestic disorder, should take into
consideration that the client is probably experiencing which imbalance?
Thiamine deficiency
A reduced iron intake
An increase in serotonin
Riboflavin malabsorption
Within a few hours of alcohol withdrawal the nurse should assess the client for the presence of
what symptoms?
Irritability and tremors
