PRACTICE QUESTIONS & VERIFIED RATIONALES (A+
GUIDE)
A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also
reports
that he is married to a female movie star and thinks that his brother wants a sexual
relationship
with her. What is the priority nursing problem for admission to the psychiatric unit?
A. Ineffective sexual patterns.
B. Impaired environmental interpretation.
C. Disturbed sensory perception.
D. Compromised family coping.
A
The RN is providing care for a client diagnosed with borderline personality disorder who has
self-inflicted lacerations on the abdomen. Which approach should the RN use when
changing
this client's dressing?
A. Provide detailed thorough explanations when cleansing wound.
B. Perform the dressing change in a non-judgmental manner.
C. Ask in a non-threatening manner why the client cut own abdomen.
D. Request another staff member assist with the dressing change.
B
,While sitting in the day room of the mental health unit, a male adolescent avoids eye
contact,
looks at the floor, and talks softly when interacting verbally with the RN. The two trade
places,
and the RN demonstrates the client's behaviors. What is the main goal of this therapeutic
technique?
A. Initiate a non-threatening conversation with the client.
B. Dialog about the ineffectiveness of his interactions.
C. Allow the client to identify the way he interacts.
D. Discuss the client's feelings when he responds.
C
An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in
the
past 2 days and weight loss of 9 lbs within the last month. Which client goal is most
important to
achieve within the first three days of treatment?
A. Meet scheduled appointment with dietitian.
B. Sleep at least 6 hours a night.
C. Understands the purpose of the medication regimen.
D. Describes the reasons for hospitalization.
B
When preparing to administer to domestic violence screening tool to a female client, which
statement should the RN provide?
,A. If your partner is abusing you, I need to ask these questions.
B. State law mandates that I ask if you are a victim of domestic violence.
C. The HCP provider needs to know if you are experiencing any domestic abuse.
D. All clients are screened for domestic abuse because it is common in our society.
D
A young adult female visits the mental health clinic complaining of diarrhea, headache,
and
muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal
limits.
During the physical assessment, the client tells the RN that her sister thinks she is neurotic
and
calls her a hypochondriac. Which response is best for the RN to provide?
A. Unless your sister has a medical education, ignore her comments.
B. I can hear that your sister comments are over-whelming you.
C. Do you think it's possible that you might be a hypochondriac?
D. Besides your sister's comments, what in your life is troubling you?
D
The RN is leading a group on the inpatient psychiatric unit. Which approach should the RN
use
during the working phase of group development?
A. Establishing a rapport with group members.
B. Clarifying the nurse's role and clients' responsibilities.
C. Discussing ways to use new coping skills learned.
, D. Helping clients identify areas of problem in their lives
D
A male client with schizophrenia is demonstrating echolalia, which is becoming annoying
to
other clients on the unit. What intervention is best for the RN to implement?
A. Isolate the client from the other clients.
B. Administer PRN sedative.
C. Avoid recognizing the behavior.
D. Escort the client to his room.
D
A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based
on
which assessment finding will the RN withhold the clonidine (Catapres) prescription?
A. Blood pressure readings of 90/62 mmHg to 92/58 mmHg.
B. Pulse rate of 68-78 BPM.
C. Temperature of 99.5-99.7 F.
D. Respiration rate of 24 breaths per minute
A
The RN on the evening shift receives report that a client is scheduled for electroconvulsive
treatment (ECT) in the morning. Which intervention should the Rn implement the evening
before