A1 PASSERS TRAINING, RESEARCH, REVIEW AND
DEVELOPMENT COMPANY
PSYCHIATRIC NURSING SET I
• The nurse at a substance abuse center answers the phone. A probation officer asks if a client is in treatment.
Thenurse responds, "No, the client you're looking for isn't here." Which statement best describes the
nurse's response?
• Correct, because she didn't give out information about the client
• A violation of confidentiality because she informed the officer that the client wasn't
there
• A breach of the principle of veracity because the nurse is misleading the officer
• Illegal, because she's withholding information from law enforcement agents
• Critical pathways of care refer to:
• a care plan that provides outcome-based guidelines with a designated length of stay.
• a care plan designed for physicians to order medications.
• a design of treatment that includes approved therapies.
• a technique in therapy to care for the client holistically.
• A nurse places a client in full leather restraints. How often must the nurse check the client's circulation?
• Once per hour
• Once per shift
•
• Every 10 to 15 minutes
• Every 2 hours
• A client in group therapy is restless. His face is flushed and he makes sarcastic remarks to group members.
Thenurse responds by saying, "You look angry." The nurse is using which technique?
• A broad, opening statement
• Reassurance
•
• Clarifying
• Making observations
• A client is presented with the treatment option of electroconvulsive therapy (ECT). After discussing the
treatmentwith the staff, the client requests that a family member come in to help him decide whether to
undergo this treatment. Which document must the client sign before undergoing ECT?
• Informed consent
• Health care power of attorney
•
• Voluntary commitment form
• Outpatient commitment form
• 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 technique?
• Presenting reality
• Making observations
•
• Restating
• Exploring
,• A client reports losing his job, not being able to sleep at night, and feeling upset with his wife. The nurse
responds,"You may want to talk about your employment situation in group today." The nurse is using which
therapeutic technique?
• Restating
• Making observations
•
• Exploring
• Focusing
• A client with antisocial personality disorder smokes in prohibited areas and refuses to follow other unit and
facility rules. The client persuades others to do his laundry and other personal chores, splits the staff, and
will work onlywith certain nurses. The care plan for this client should focus primarily on:
• consistently enforcing unit rules and facility policy.
• isolating the client to decrease contact with easily manipulated clients.
• engaging in power struggles with the client to minimize manipulative behavior
• using behavior modification to decrease negative behavior by using negative reinforcement.
• During the mental status examination, a client may be asked to explain such proverbs as "Don't cry over
spilledmilk." The purpose of this is to evaluate the client's ability to think
• rationally.
• concretely.
•
• abstractly.
• tangentially.
• Conditions necessary for the development of a positive sense of self-esteem include:
• consistent limits.
• critical environment
•
• inconsistent boundaries.
• physical discipline
• A client with bipolar disorder is taking lithium carbonate (Eskalith) 300 mg t.i.d. His lithium level is 2.7
mEq/L. In assessing the client at his clinic visit, the nurse finds no evidence of lithium toxicity. The first
assessment questionthe nurse should ask before ordering another blood test is:
• whether the client is embarrassed or afraid to report medication problems.
• whether the client is experiencing depression and having suicidal ideation.
• whether the client understands why he's taking this medication.
• when the client took his last dose of lithium.
• A client with paranoid schizophrenia started risperidone (Risperdal) 2 weeks ago. Today, he tells the
nurse hefeels like he has the flu. The nurse's assessment reveals the following: temperature 104.4° F
(40.2° C), respirations 24 breaths/minute, blood pressure 130/102 mm Hg, pulse rate 120 beats/minute.
The nurse alsonotes muscle stiffness and pain, excessive sweating and salivation, and changes in
mental status. The nursesuspects the client is experiencing:
• the flu.
• malignant hyperthermia.
•
• neuroleptic malignant syndrome.
• Septicemia
• Nursing care for a client after electroconvulsive therapy (ECT) should include:
• nothing by mouth for 24 hours after the treatment because of the anesthetic agent.
• bed rest for the first 8 hours after a treatment.
, • assessment of short-term memory loss.
• no special care.
• Which action demonstrates the role of the psychiatric nurse in primary prevention?
1
• Handling crisis intervention in an outpatient setting
• Visiting a client's home to discuss medication management
• Conducting a post discharge support group
• Providing sexual education classes for adolescents
• What is the primary indication for electroconvulsive therapy (ECT)?
• Severe agitation
• Antisocial behavior
• Noncompliance with treatment
• Major depression with psychoticfeatures
• Which nursing intervention is most important when restraining a violent client?
• Reviewing facility policy regarding how long the client may be restrained
• Preparing an as-needed dose of the client's psychotropic medication
• Checking that the restraints have been applied correctly
• Asking if the client needs to use the bathroom or is thirsty
• Touching other people without their permission, reading someone else's mail, and using personal
possessionswithout asking permission are all examples of:
• antisocial behavior.
• manipulation.
•
• poor boundaries.
• passive-aggressive behavior.
• Additive central nervous system (CNS) depression can occur when combining a barbiturate with which drug?
• Methylphenidate (Ritalin)
• Cocaine
•
• Amitriptyline (Elavil)
• Amphetamine (Adderall)
• A client on the behavioral health unit tells a nurse that she was raped 5 months earlier. During the nurse's
assessment of this client's sleep patterns, the client complains of having difficulty falling asleep and
staying asleep. She attributes her irritability to sleep deprivation. Further questioning reveals that the
client can't recall details of the rape, and feels detached when she has sex with her husband. The nurse
recognizes that this clientis experiencing symptoms of what disorder?
• Antisocial personality disorder
• Cypridophobia
•
, • Anhedonia
• Posttraumatic stress disorder (PTSD)
• A client diagnosed with anxiety disorder is ordered buspirone (BuSpar). Teaching instructions for buspirone
shouldinclude:
• a warning that immediate sedation can occur with a resultant drop in pulse.
• a reminder of the need to schedule blood work 1 week after initiating therapy to check blood
levels of thedrug.
• a warning about medication-related incidence of neuroleptic malignant syndrome.
• a warning about the drug's delayed therapeutic effect, which occurs in 14 to 30 days.
• After seeking help at an outpatient mental health clinic, a client who was raped while walking her dog is
diagnosedwith posttraumatic stress disorder (PTSD). Three months later, the client returns to the clinic,
complaining of feelings of fear, loss of control, and helplessness. Which nursing intervention is most
appropriate for this client?
• Exploring the meaning of the traumatic event with the client
• Allowing the client time to heal
• Giving the client sleep medication, to take as ordered, to restore a normal sleep-wake cycle
• Encouraging the client to attend a rape therapy group
• During alprazolam (Xanax) therapy, the nurse should be alert for which dose-related adverse reaction?
• Ataxia
• Hepatomegaly
•
• Urticaria
• Rash
• A nurse is interviewing a client with posttraumatic stress disorder (PTSD) when a loud, booming noise
from a passing car's radio rattles the windows. The client jumps onto a chair, wide-eyed and frantic. Which
statement bythe nurse is the most therapeutic response?
• "There's no reason to be afraid of a car radio."
• "Take my hand and I'll help you down."
• "Have you experienced this kind of thing before?"
• "What kinds of feelings are you experiencing?"
• A nurse is caring for a client diagnosed with panic disorder. The client begins to hyperventilate. How
should thenurse respond initially?
• Stay with the client during the anxiety attack.
• Shout for help and obtain assistance.
• Teach the client to perform relaxation exercises.
• Help the client explore the reason for his anxiety.
• A client is admitted to the emergency department with chest pain, palpitations, vertigo, and diaphoresis.
When initial assessment indicates no physiological basis for these complaints, the client is referred to a
psychiatric clinical nurse-specialist. After determining that the client has experienced four similar episodes
in the past month,the nurse specialist suspects that the client has:
• panic disorder.
• depression.
•
• schizophrenia.
• obsessive-compulsive disorder.
• A nurse is in the dining room and overhears a new nurse tell a client with body dysmorphic disorder that
she's much too thin and must eat more before she can go home. The client bursts into tears and runs out of
the diningroom. What is the best way for the nurse to address this situation?
• Ask the new nurse how much she knows about the client's specific diagnosis.
• Inform the new nurse that she handled the situation in an inappropriate manner.
• Ask the new nurse why she made that statement to the client.
DEVELOPMENT COMPANY
PSYCHIATRIC NURSING SET I
• The nurse at a substance abuse center answers the phone. A probation officer asks if a client is in treatment.
Thenurse responds, "No, the client you're looking for isn't here." Which statement best describes the
nurse's response?
• Correct, because she didn't give out information about the client
• A violation of confidentiality because she informed the officer that the client wasn't
there
• A breach of the principle of veracity because the nurse is misleading the officer
• Illegal, because she's withholding information from law enforcement agents
• Critical pathways of care refer to:
• a care plan that provides outcome-based guidelines with a designated length of stay.
• a care plan designed for physicians to order medications.
• a design of treatment that includes approved therapies.
• a technique in therapy to care for the client holistically.
• A nurse places a client in full leather restraints. How often must the nurse check the client's circulation?
• Once per hour
• Once per shift
•
• Every 10 to 15 minutes
• Every 2 hours
• A client in group therapy is restless. His face is flushed and he makes sarcastic remarks to group members.
Thenurse responds by saying, "You look angry." The nurse is using which technique?
• A broad, opening statement
• Reassurance
•
• Clarifying
• Making observations
• A client is presented with the treatment option of electroconvulsive therapy (ECT). After discussing the
treatmentwith the staff, the client requests that a family member come in to help him decide whether to
undergo this treatment. Which document must the client sign before undergoing ECT?
• Informed consent
• Health care power of attorney
•
• Voluntary commitment form
• Outpatient commitment form
• 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 technique?
• Presenting reality
• Making observations
•
• Restating
• Exploring
,• A client reports losing his job, not being able to sleep at night, and feeling upset with his wife. The nurse
responds,"You may want to talk about your employment situation in group today." The nurse is using which
therapeutic technique?
• Restating
• Making observations
•
• Exploring
• Focusing
• A client with antisocial personality disorder smokes in prohibited areas and refuses to follow other unit and
facility rules. The client persuades others to do his laundry and other personal chores, splits the staff, and
will work onlywith certain nurses. The care plan for this client should focus primarily on:
• consistently enforcing unit rules and facility policy.
• isolating the client to decrease contact with easily manipulated clients.
• engaging in power struggles with the client to minimize manipulative behavior
• using behavior modification to decrease negative behavior by using negative reinforcement.
• During the mental status examination, a client may be asked to explain such proverbs as "Don't cry over
spilledmilk." The purpose of this is to evaluate the client's ability to think
• rationally.
• concretely.
•
• abstractly.
• tangentially.
• Conditions necessary for the development of a positive sense of self-esteem include:
• consistent limits.
• critical environment
•
• inconsistent boundaries.
• physical discipline
• A client with bipolar disorder is taking lithium carbonate (Eskalith) 300 mg t.i.d. His lithium level is 2.7
mEq/L. In assessing the client at his clinic visit, the nurse finds no evidence of lithium toxicity. The first
assessment questionthe nurse should ask before ordering another blood test is:
• whether the client is embarrassed or afraid to report medication problems.
• whether the client is experiencing depression and having suicidal ideation.
• whether the client understands why he's taking this medication.
• when the client took his last dose of lithium.
• A client with paranoid schizophrenia started risperidone (Risperdal) 2 weeks ago. Today, he tells the
nurse hefeels like he has the flu. The nurse's assessment reveals the following: temperature 104.4° F
(40.2° C), respirations 24 breaths/minute, blood pressure 130/102 mm Hg, pulse rate 120 beats/minute.
The nurse alsonotes muscle stiffness and pain, excessive sweating and salivation, and changes in
mental status. The nursesuspects the client is experiencing:
• the flu.
• malignant hyperthermia.
•
• neuroleptic malignant syndrome.
• Septicemia
• Nursing care for a client after electroconvulsive therapy (ECT) should include:
• nothing by mouth for 24 hours after the treatment because of the anesthetic agent.
• bed rest for the first 8 hours after a treatment.
, • assessment of short-term memory loss.
• no special care.
• Which action demonstrates the role of the psychiatric nurse in primary prevention?
1
• Handling crisis intervention in an outpatient setting
• Visiting a client's home to discuss medication management
• Conducting a post discharge support group
• Providing sexual education classes for adolescents
• What is the primary indication for electroconvulsive therapy (ECT)?
• Severe agitation
• Antisocial behavior
• Noncompliance with treatment
• Major depression with psychoticfeatures
• Which nursing intervention is most important when restraining a violent client?
• Reviewing facility policy regarding how long the client may be restrained
• Preparing an as-needed dose of the client's psychotropic medication
• Checking that the restraints have been applied correctly
• Asking if the client needs to use the bathroom or is thirsty
• Touching other people without their permission, reading someone else's mail, and using personal
possessionswithout asking permission are all examples of:
• antisocial behavior.
• manipulation.
•
• poor boundaries.
• passive-aggressive behavior.
• Additive central nervous system (CNS) depression can occur when combining a barbiturate with which drug?
• Methylphenidate (Ritalin)
• Cocaine
•
• Amitriptyline (Elavil)
• Amphetamine (Adderall)
• A client on the behavioral health unit tells a nurse that she was raped 5 months earlier. During the nurse's
assessment of this client's sleep patterns, the client complains of having difficulty falling asleep and
staying asleep. She attributes her irritability to sleep deprivation. Further questioning reveals that the
client can't recall details of the rape, and feels detached when she has sex with her husband. The nurse
recognizes that this clientis experiencing symptoms of what disorder?
• Antisocial personality disorder
• Cypridophobia
•
, • Anhedonia
• Posttraumatic stress disorder (PTSD)
• A client diagnosed with anxiety disorder is ordered buspirone (BuSpar). Teaching instructions for buspirone
shouldinclude:
• a warning that immediate sedation can occur with a resultant drop in pulse.
• a reminder of the need to schedule blood work 1 week after initiating therapy to check blood
levels of thedrug.
• a warning about medication-related incidence of neuroleptic malignant syndrome.
• a warning about the drug's delayed therapeutic effect, which occurs in 14 to 30 days.
• After seeking help at an outpatient mental health clinic, a client who was raped while walking her dog is
diagnosedwith posttraumatic stress disorder (PTSD). Three months later, the client returns to the clinic,
complaining of feelings of fear, loss of control, and helplessness. Which nursing intervention is most
appropriate for this client?
• Exploring the meaning of the traumatic event with the client
• Allowing the client time to heal
• Giving the client sleep medication, to take as ordered, to restore a normal sleep-wake cycle
• Encouraging the client to attend a rape therapy group
• During alprazolam (Xanax) therapy, the nurse should be alert for which dose-related adverse reaction?
• Ataxia
• Hepatomegaly
•
• Urticaria
• Rash
• A nurse is interviewing a client with posttraumatic stress disorder (PTSD) when a loud, booming noise
from a passing car's radio rattles the windows. The client jumps onto a chair, wide-eyed and frantic. Which
statement bythe nurse is the most therapeutic response?
• "There's no reason to be afraid of a car radio."
• "Take my hand and I'll help you down."
• "Have you experienced this kind of thing before?"
• "What kinds of feelings are you experiencing?"
• A nurse is caring for a client diagnosed with panic disorder. The client begins to hyperventilate. How
should thenurse respond initially?
• Stay with the client during the anxiety attack.
• Shout for help and obtain assistance.
• Teach the client to perform relaxation exercises.
• Help the client explore the reason for his anxiety.
• A client is admitted to the emergency department with chest pain, palpitations, vertigo, and diaphoresis.
When initial assessment indicates no physiological basis for these complaints, the client is referred to a
psychiatric clinical nurse-specialist. After determining that the client has experienced four similar episodes
in the past month,the nurse specialist suspects that the client has:
• panic disorder.
• depression.
•
• schizophrenia.
• obsessive-compulsive disorder.
• A nurse is in the dining room and overhears a new nurse tell a client with body dysmorphic disorder that
she's much too thin and must eat more before she can go home. The client bursts into tears and runs out of
the diningroom. What is the best way for the nurse to address this situation?
• Ask the new nurse how much she knows about the client's specific diagnosis.
• Inform the new nurse that she handled the situation in an inappropriate manner.
• Ask the new nurse why she made that statement to the client.
