QUESTION 1
A patient has been admitted to an inpatient psychiatric facility in a bipolar manic episode with symptoms of poor impulse control, flamboyant affect, and sexual disinhibition. In the nursing team meeting, the RN discusses the patient’s immediate goals. Which patient outcome will the RN emphasize with the team?
a. The patient will interact appropriately with others.
b. The patient will sleep 8 hours per night without medication.
c. The patient will verbalize that hallucinations have decreased.
d. The patient will maintain a stable weight.
QUESTION 2
What must the RN consider when assessing cultural influences for individuals with mood disorders?
a. Substance abuse is more common in some cultures.
b. Immigrants tend to have more strong family support.
c. Emotions have different meaning in different cultures.
d. Firmly held religious beliefs often counteract mood perceptions.
QUESTION 3
Which action by the RN best demonstrates the ethical principle of beneficence as applied to a client with severe mental illness?
a. Determining how to ensure safety when the client refuses their medication.
b. Asking the client’s representative to give consent for a procedure.
c. Being honest about the client’s diagnosis, prognosis, and treatment.
d. Acting as an advocate for the client to secure essential mental-health services.
QUESTION 4
A client with an inappropriate affect disorder is being cared for by a team that includes an RN, an LPN, and a UAP. The RN explains to the team members that they may notice which of the following client behaviors when they are providing care?
a. Finding enjoyment in small things.
b. Crying when learning sad news.
c. Absence of a response to a situation.
d. Experiencing extreme pleasure.
QUESTION 5
The RN contacts the healthcare provider regarding a client’s sudden onset of symptoms of depression and learns that which medication may be responsible?
a. acetaminophen (Tylenol)
b. ethinyl estradiol/norethindrone (Ortho-Novum)
c. alprazolam (Xanax)
d. quinapril (Accupril)
QUESTION 6
Which topics will the RN include when teaching a client about the side effects associated with the use of Selective Serotonin Reuptake Inhibitors (SSRIs)?
a. Weight gain and blurry vision.
b. Hypotension and tachycardia.
c. Gastrointestinal distress and sexual dysfunction.
d. Cardiac dysrhythmias and seizures.
QUESTION 7
The RN should include which interventions in the plan of care for a client admitted to the mental health unit after an attempted suicide? Select all that apply.
a. Administer medications and watch the patient swallow them.
b. Provide one-to-one contact with the patient.
c. Make rounds at the same time every hour.
d. Insist on a verbal contract of no harm.
e. Orient the patient to reality.
QUESTION 8
Which assessment data supports the presence of acute delirium in a patient?
a. The cause is from irreversible disturbances in brain function.
b. Memory impairment onset is sudden.
c. Deterioration is consistent with some lucid moments.
d. Symptoms have been present for a few months.
QUESTION 9
The RN would be concerned about which food in the diet of a client admitted with toxic effects of a prescribed Selective Serotonin Reuptake Inhibitor (SSRI)?
a. Chocolate
b. Milk
c. Cheese
d. Grapefruit
QUESTION 10
The RN notes which assessment data are consistent with a patient experiencing Bipolar Disorder? Select all that apply.
a. Inappropriate sexual behavior.
b. Neat and clean groomed appearance.
c. Sleeping 8 hours per night.
d. Refusal to get dressed in the morning.
e. Excessive spending of money.
QUESTION 11
A client who has been taking clozapine for the past two months reports sudden onset of sore throat, fever, and malaise. Which data is most concerning to the RN?
Temperature of 101° F
White blood count of 3,000/mm3
Hematocrit of 46%
Pulse of 110
QUESTION 12
A hospitalized adolescent who was born anatomically male has the self-perception of being female Which of the following actions by the RN is most appropriate for this client?
a. Arrange for an Endocrine consultation.
b. Arrange for the Pastoral Care Department to visit.
c. Place the client with a female roommate.
d. Refer to the client using female pronouns.
QUESTION 13
Which nursing intervention is appropriate for a patient with the nursing diagnosis Impaired memory after returning from a military deployment where a head injury was sustained?
a. Report any noticeable cognitive changes to health care provider.
b. Assess for generalized twitching of extremities.
c. Teach about ways to improve attention span.
d. Assist with confusion when trying to formulate sentences.
QUESTION 14
An adult patient with no prior behavioral health history was involuntarily admitted to the mental health unit with a diagnosis of Bipolar Mania after the patient’s brother noticed recent episodes of wild spending sprees, shoplifting, and confrontations with authority figures. When the brother inquires as to what caused the problem, which is the appropriate response by the RN?
a. “The disorder is hereditary and, therefore, twins are also at risk.”
b. “Both biological and psychosocial factors are believed to be involved.”
c. “It is frequently triggered by excessive alcohol use.”
d. “The disorder is characterized by brain chemistry disturbances.”
QUESTION 15
When educating a client about ethnic and cultural factors that predispose a person to alcohol addiction, which of the following will the RN include?
a. Native-American heritage
b. Japanese heritage
c. Italian heritage
d. French heritage
QUESTION 16
A client in alcohol withdrawal has been prescribed lorazepam (Ativan) 2 mg IM, one stat dose.
The pharmacy label reads: 0.5 ANSWER
QUESTION 17
Which is an appropriate outcome when caring for a client with delusions of persecution?
a. Reduction of symptoms.
b. Decrease in medication doses.
c. Function without medications.
d. Return to employment.
QUESTION 18
Which of the following would be an expected outcome for the nursing diagnosis Imbalanced nutrition: less than body requirements related to binging and purging?
a. Client will gain a prescribed amount of weight weekly.
b. Client will be able to identify foods and situations that are triggers.
c. Client will negotiate a contract for meals eaten.
d. Client will measure all portions carefully.
QUESTION 19
The RN asks an LPN to sit with a highly anxious client and engage in light conversation while admission paperwork is finalized. Which statement made by the LPN to the client and overheard by the RN is appropriate?
a. “You must be feeling pretty stressed right now.”
b. “You could use some anti-anxiety medication.”
c. “Everything will be all right, so try to relax.”
d. “I wouldn’t worry about that if I were you.”
QUESTION 20
The RN is developing a plan of care for a client with Schizophrenia who is experiencing visual hallucinations. What would be an expected short-term outcome for the nursing diagnosis of Anxiety related to unconscious conflict with reality?
a. The client will accept the anxiety in the presence of the hallucination with next occurrence.
b. The client will discuss the content of the hallucinations within one week.
c. The client will state the images can be stopped at any time.
d. The client will learn to use voice dismissal prior to discharge.
QUESTION 21
A hospitalized client who had been taking low-dose chlordiazepoxide as a sleep aid for several years has stopped this medication abruptly. The RN can expect to see withdrawal symptoms begin how long after cessation of the medication?
a. 3 days afterwards
b. 5-8 days afterwards
c. 2-4 hours afterwards
d. 12-24 hours afterwards
QUESTION 22
A 40-year-old client with new-onset Schizophrenia has been taking fluphenazine for four days and begins to exhibit symptoms of muscular weakness, which is an indication of:
a. Dystonia
b. Akinesia
c. Akathisia
d. Pseudoparkinsonism
QUESTION 23
Which of the following observations should make the RN suspect possible parental child abuse when assessing an 8-year-old child that was brought to the emergency room after a school sports injury?
a. Child starts crying, saying he wants to go home.
b. Child refuses to allow the nurse to examine him.
c. Child complains that his teammates are “mean.”
d. Child recoils when father enters the exam room.
QUESTION 24
Which RN intervention best supports a care plan based on Maslow’s physiological needs?
a. Initiating contact precautions.
b. Keeping the side rails up on the bed.
c. Involving the family in the plan of care.
d. Maintaining an oxygen saturation of 95%.
QUESTION 25
The RN is assessing a newly admitted client using the Michigan Alcoholism Screening Test (MAST). When the client responds affirmatively to the question, “Have you ever lost friends because of your drinking?”, the score of 5 is assigned by the RN. What does this indicate about the client’s use of alcoholic beverages?
a. The client has a possible problem with alcohol use.
b. The client previously had a problem with alcohol use, but is now recovered.
c. The client has no problems with alcohol use.
d. The client has a definite problem with alcohol use.
QUESTION 26
Which medication is contraindicated for adolescents who are being treated for major depressive disorder?
a. fluoxetine (Prozac)
b. escitalopram (Lexapro)
c. imipramine (Tofranil)
d. paroxetine (Paxil)
QUESTION 27
Which behavior would first alert the RN that a co-worker might be impaired due to substance abuse?
a. Preferring to eat alone during lunch.
b. Unexplained disappearance from the nursing unit.
c. Clients reporting unrelieved pain.
d. Discrepancies in the end-of-shift count.
QUESTION 28
Which side effect would the RN address when providing patient teaching for a client taking typical (traditional) antipsychotic medications?
a. Hyperactivity
b. Excessive energy
c. Dystonia
d. Urinary frequency
QUESTION 29
Which nursing interventions would be appropriate when providing care for a patient who is exhibiting symptoms of a panic attack? Select all that apply.
a. Instruct the patient to take slow deep breaths.
b. Encourage the patient to attend group therapy.
c. Loosen any restrictive clothing.
d. Decrease external stimuli and noise.
e. Increase the volume on the television to distract the patient.
QUESTION 30
Why would the RN ask a client about her use of St. John’s Wort as an alternative treatment for Depression?
a. The cost of the treatment may be more than that of standard therapies.
b. It can interfere with the action and effectiveness of other medications.
c. A prescription is required to obtain it from a pharmacy.
d. Alternative medicines are not effective in the treatment of depression.
QUESTION 31
Which statement is accurate about the admission status of a client with a longstanding history of Depression who seeks admission for psychiatric treatment due to thoughts of self-harm?
a. The client must have a family member authorize the admission.
b. The client relinquishes all rights to have a say in treatment decisions.
c. By law, the maximum duration of this admission may only be 72 hours.
d. The client may leave the hospital at any time unless deemed a danger to self or others.
QUESTION 32
An LPN is assisting with the care of a client receiving an antipsychotic medication for the treatment of Schizophrenia. The RN tells the LPN to report immediately if which of the following client symptoms is noticed?
a. Excessive drooling of saliva.
b. Smacking of the lips.
c. Shouting of obscenities.
d. Tremors at rest.
QUESTION 33
Which nursing intervention would the RN include in the plan of care for an autistic client with the nursing diagnosis of Self-mutilation?
a. Set time limits for meals.
b. Maintain a structured schedule of daily activities.
c. Offer sympathy during episodes of self-mutilation.
d. Rotate staff members who care for the client.
QUESTION 34
The RN is conducting a 15-minute mental health assessment for a client in the manic phase of Bipolar Disorder. What is the rationale for limiting the length of the assessment?
a. Too many questions can lead to depression.
b. A longer period of time may overstimulate the client.
c. The client will feel pressured to keep talking.
d. The client will lose interest if it is longer.
QUESTION 35
The RN is aware that which would occur if needs were not met during the latency stage of Freud’s development?
a. Disorganization, untidiness and destructiveness.
b. Identification with the opposite-gender parent.
c. Inability to trust others.
d. Inability to develop relationships with other children.
QUESTION 36
Which clinical manifestation will the RN expect to observe in a patient taking the medication disulfiram (Antabuse) who presents to the emergency room where a blood alcohol level of 125 mg/dL is obtained?
a. Nausea and vomiting
b. Sweating
c. Headache
d. Heart failure
QUESTION 37
Which behavior would the RN interpret as an inappropriate affect?
a. Smiling when receiving news of a birth of a child.
b. Crying when being told that the family pet has died.
c. Reacting calmly when a child drops food on the floor.
d. Giggling while reading the news of a fatal car accident.
QUESTION 38
Which RN intervention is the priority when caring for a patient with Borderline Personality Disorder who displays occasional self-destructive behaviors?
a. Place the patient under continuous observation.
b. Minimize physical activity to discourage violent impulses.
c. Encourage the patient to explore triggers for the behaviors.
d. Contact the healthcare provider for an order for restraints.
QUESTION 39
To create a safe environment for a client with Alzheimer’s disease who wanders, the RN instructs the LPN to assist with which of the following interventions?
a. Encourage independence with preparing meals.
b. Provide an enclosed area for pacing.
c. Remove all diversions such as television and radio.
d. Maintain a varied schedule for meals and toileting.
QUESTION 40
Which nursing interventions are important for the RN to incorporate into a care plan for a client with an Obsessive-Compulsive Disorder? Select all that apply.
a. Tell the patient to spend more time alone.
b. Involve the patient in group therapy activities.
c. Discourage physical activity as it might cause fatigue.
d. Encourage journaling to sort out feelings.
e. Teach the patient to breathe slowly and deeply.
QUESTION 41
What are the expected cycle of battering characteristics for a client who has been the victim of domestic violence for many years? Select all that apply.
a. Abuser has low tolerance for frustration.
b. Victim enjoys being abused.
c. Abuser fears that the partner will leave.
d. Abuser is expected to stop being abusive.
QUESTION 42
A rural mother with a low birth-weight infant was charged with abusing her child. Which factor has been shown to be most predictive of the potential for child abuse?
a. Depressive symptoms
b. Lack of social support
c. Minimal financial resources
d. Isolation of rural environment
QUESTION 43
Which would be a common psychosocial expected outcome for a patient with any eating disorder?
a. A positive body image.
b. Effective physical mobility.
c. Regular meal times.
d. Weight change of ten pounds.
QUESTION 44
The RN is caring for a woman who experienced interpersonal violence from her spouse of 15 years. Which nursing intervention would assist with empowering this patient?
a. Ask the patient if she knows why this happened to her.
b. Help her recognize ways she is dependent on her abuser.
c. Identify a family member to help solve family problems.
d. Teach her about the use of conflict resolution.
QUESTION 45
An LPN reports to the RN that while caring for their Asian client, the client always looks away. The RN informs the LPN that which principle likely explains the client’s behavior?
a. The client likely feels ashamed about the mental illness.
b. The client is exhibiting a cultural norm and it should be respected.
c. The client needs to be left alone for a few hours to cope with the illness.
d. The client is seriously mentally ill and unable to interact with staff.
QUESTION 46
What is the priority action that considers both legal and ethical principles when the RN suspects child abuse?
a. Call the child abuse hotline.
b. Document suspicions in the medical record.
c. Ask other nurses to validate any uncertainties.
d. Wait until more evidence is available.
QUESTION 47
Which is considered a positive symptom of Schizophrenia?
a. Withdrawal
b. Limited speech
c. Associative looseness
d. Flat affect
QUESTION 48
Two RNs are having a discussion. One states, “I have attained the professional goals I have set for myself; I am a nurse manager with national certification in emergency nursing.” Which of Maslow’s hierarchy of needs does this statement represent?
a. Physiological
b. Love and belonging
c. Safety
d. Self-actualization
QUESTION 49
A client tells the unlicensed assistive personnel (UAP) “I am so depressed every year around the holidays.” What is the RN’s appropriate response when the UAP asks the RN what the client’s statement means?
a. “The client should always try to take vacation at the end of December.”
b. “It is apparent this client must be seeing a counselor on a regular basis.”
c. “The client may be experiencing seasonal affective disorder.”
d. “It is likely a case of moderate anxiety that should be treated.”
QUESTION 50
Which question should the RN ask of a client who is at risk for suicide?
a. Have you given away any of your personal belongings recently?
b. Are you planning on changing jobs in the near future?
c. How has your life improved over the last month?
d. Can you describe your plans for retirement?
QUESTION 51
Which of the following medications would the RN expect to administer to prevent relapse for alcohol abuse?
a. buproprion (Wellbutrin)
b. gabapentin (Neurontin)
c. disulfiram (Antabuse)
d. methadone (Dolophine)
QUESTION 52
The RN observes a school–aged patient with Autism giggling uncontrollably while slapping her head. What is the RN’s appropriate interpretation of this behavior?
a. A common manifestation seen with autism.
b. An untoward reaction to a medication.
c. The existence of a severe headache.
d. The development of a seizure disorder.
QUESTION 53
The RN would expect to assess which behavior in a client admitted with a medical diagnosis of Bipolar Disorder and inappropriate affect?
a. Crying and wringing of hands while talking.
b. Jumping up and down on the couch while smiling.
c. Eyes cast downward with no display of emotion.
d. Laughing hysterically while talking about a sad event.
QUESTION 54
The RN is caring for a client with Schizophrenia who states, “I am an Olympic gold medalist.” How would the RN assess this client statement?
a. Delusions of grandeur
b. Ideas of reference
c. Inappropriate affect
d. Hallucinations
QUESTION 55
The interprofessional team has met with a patient and selected the nursing diagnosis Post-trauma syndrome. What would be an appropriate short-term goal for this nursing diagnosis?
a. Patient will demonstrate ability to deal with emotional reactions by discharge.
b. Patient will move through stages of grief by discharge.
c. Patient will verbalize consistent details of the trauma incurred by discharge.
d. Patient will discuss lifestyle changes by discharge.
QUESTION 56
Which statement made by a client in a mental health clinic demonstrates the use of denial as a coping measure?
a. “Winter weather always makes me feel more anxious.”
b. “I am going to smoke a pack of cigarettes to make myself feel better.”
c. “I am not going to come in anymore, as I have no problems.”
d. “It is my doctor’s fault that I am not improving.”
QUESTION 57
What is the RN’s priority action for a client experiencing auditory hallucinations?
a. Administer the ordered antipsychotic medication.
b. Inform the health care provider.
c. Tell the client that the voices are not real.
d. Maintain a safe environment.
QUESTION 58
The RN is evaluating a client with Dependent Personality Disorder after several sessions of therapeutic communication. Which recent client behavior indicates that the sessions were beneficial?
a. Client joins group activities on the unit.
b. Client begins to follow the rules of the unit
c. Client initiates a project or activity.
d. Client no longer expresses suicidal ideation.
QUESTION 59
Which assessment supports the RN’s choice of Complicated grieving as a nursing diagnosis for a client admitted to the mental health unit? Select all that apply.
a. Eating small meals throughout the day.
b. Difficulty getting out of bed in the morning.
c. Becoming increasingly withdrawn.
d. Going to work early in the morning.
e. Refusing to shower or bathe.
QUESTION 60
The RN informs the LPN that which signs or symptoms might be noticed while providing care to a client admitted for Depression? Select all that apply.
a. Inability to make decisions
b. Crying spells
c. Impulse control
d. Feelings of worthlessness
e. Exaggerated sexual drive
QUESTION 61
A patient with hypochondriasis would exhibit which characteristic?
a. Fearful response to loud noises.
b. Shortness of breath and palpitations.
c. Frequent visits to the doctor for the same complaint.
d. Constant crying and excessive sleeping.
QUESTION 62
Which assessment data is associated with a patient who has the medical diagnosis of Anorexia Nervosa?
a. Eating eight small meals a day.
b. Eating large amounts of unhealthy food.
c. Eating and inducing vomiting immediately after.
d. Eating minimal amounts of food and fluid.
QUESTION 63
Which is the appropriate action by the RN when a client treated for depression states, “I am all better now, I feel great?”
a. Watchfully observe for suicidal ideation.
b. Transfer the client to a private room.
c. Prepare the client for discharge home.
d. Hold the next dose of anti-anxiety medication.
QUESTION 64
A client with Obsessive-Compulsive Disorder washes his hands 20-30 times per day and they are raw and bleeding. What would be an appropriate question for the RN to ask this client?
a. “Can you describe how you feel when you wash your hands?”
b. “Are your hands actually soiled that many times a day?”
c. “What is making you feel so anxious?”
d. “Why do you keep washing your hands so many times a day?”
QUESTION 65
The RN making a home visit is teaching the family of a patient who has a diagnosis of Dementia how to care for the patient. Which information must be included in the teaching plan?
a. Encouraging the patient to live alone.
b. Taking away the car keys.
c. Providing mobility aids for showering.
d. Allowing the patient to cook meals independently.
QUESTION 66
A toddler has been brought to the Emergency Room by the parents. Upon assessment the RN notices round-shaped burn marks on the upper arms and thighs of the patient. What is the legal responsibility of the RN at this time?
a. Identify the marks as cigarette burns and confront the parents.
b. Call the police and have the parents arrested.
c. Contact child protective services and detain the child from discharge.
d. Treat the patient and follow-up with child protective services once the family has returned home.
QUESTION 67
The RN has selected Chronic low self-esteem as the priority nursing diagnosis for a client admitted with a medical diagnosis of Depression. Which intervention is appropriate for this nursing diagnosis?
a. Ensure environment is safe.
b. Assess stage of grieving process.
c. Establish trusting relationship.
d. Maintain close observation.
QUESTION 68
What is the RN’s most appropriate response to a client who is experiencing a Post-Traumatic Stress Disorder (PTSD) reaction?
a. “You are safe here and in good hands.”
b. “You probably think you are back in a war zone.”
c. “It’s not that bad, try to relax.”
d. “Tell me what you are experiencing right now.”
QUESTION 69
A client with Borderline Personality Disorder has been exhibiting frequent, violent temper outbursts on the mental health unit. Which outcome would be most appropriate for this client?
a. Client will express anger appropriately.
b. Client will stop exploiting others on the unit.
c. Client will be able to express his emotions.
d. Client will interact with others on the unit.
QUESTION 70
Which data would the RN expect to assess for a patient with Alzheimer’s Disease? Select all that apply.
a. Safety due to wandering.
b. Increase in alertness.
c. Decline in short-term memory.
d. Depressed affect.
e. Ability to read books.
QUESTION 71
A client’s health record indicates Stage 4 Alzheimer’s disease with recent episodes of confabulation. The RN instructs the LPN on the team to report if which of the following client behaviors is noticed?
a. Exhibits short-term memory loss.
b. Makes up things to fill in memory gaps.
c. Acts in an inappropriate manner.
d. Becomes disoriented at night.
QUESTION 72
What is the appropriate RN response when the family of a patient diagnosed with Alzheimer’s Disease asks the RN why it is necessary to have referrals to other types of healthcare providers?
a. “Symptoms will get worse and then improve.”
b. “There will be a change in cognition and ability to function.”
c. “The care involves excessive work for one provider.”
d. “Alzheimer’s will impact vital physical functioning.”
QUESTION 73
Which nursing intervention is appropriate to use for the nursing diagnosis Deficient knowledge related to initiation of new medications for treatment of anxiety?
a. Consult the health care provider to come and explain the medications.
b. Provide written materials about the medication.
c. Administer all medications on time.
d. Ask the family to explain the medication to the patient.
QUESTION 74
Which assessment supports the presence of alcohol intoxication?
a. Slow, steady gait
b. Intense focus on work
c. Pale face
d. Nystagmus
QUESTION 75
Which assessment findings indicate to the RN that a client is exhibiting symptoms of a moderate anxiety reaction?
a. Chest pain, diaphoresis and fear of dying.
b. Increased perception and restlessness.
c. Palpitations and hyperventilation.
d. Trembling, decreased concentration and gastric discomfort.
QUESTION 76
In which circumstance would it be appropriate for the RN to breach confidentiality?
a. A family member is requesting protected health information.
b. A neighbor asks the RN why the patient was admitted.
c. A patient is a danger to themselves or others.
d. A newspaper phones the hospital seeking information.
QUESTION 77
Following hospitalization, an older adult patient starts to wander the halls and becomes confused during the evening hours. The RN would anticipate the use of which medication to treat the symptoms?
a. galantimine (Razadyne)
b. haloperidol (Haldol)
c. fluoxetine (Prozac)
d. clonazepam (Klonopin)
QUESTION 78
A client with hypertension who takes a beta-blocker has been started on an MAOI after a poor therapeutic response to other classes of antidepressant medication. The RN educates the client the interaction of these two (2) medications could result in which side effect?
a. Seizures
b. Bradycardia
c. Increased bleeding
d. Tachycardia
QUESTION 79
What is the appropriate RN response to the adult daughter of a patient with the medical diagnosis of Alzheimer’s Disease who asks the RN when the newly prescribed medication, donepezil (Aricept), will begin prevention of further degeneration for her mother?
a. If this drug does not prevent deterioration, others can be prescribed.”
b. “The drug does not alter the progress of the disease but temporarily relieves symptoms.”
c. “It will take at least three months for the medication to take full effect.”
d. “Blood tests will need to be performed periodically to ensure the correct dosage.”
QUESTION 80
What is the appropriate nursing action for the RN to take when caring for a patient with Anorexia Nervosa who insists on chewing each bite of food 25 times before swallowing?
a. Consult with the dietician for other food choices.
b. Talk to the patient about why this is occurring.
c. Tell the patient it is not necessary to chew that many times.
d. Do nothing as this ritual helps decrease anxiety.
