Answers and Rationale Psychiatric Nursing Practice Test Part 1
1. C. Total abstinence is the only effective treatment for alcoholism.
2. A. Hallucinations are visual, auditory, gustatory, tactile or olfactory perceptions that have no basis in reality.
3. D. The Nurse has a responsibility to observe continuously the acutely suicidal client. The Nurse should watch for clues, such as communicating suicidal thoughts, and messages; hoarding medications and talking about death.
4. B. Establishing a consistent eating plan and monitoring client’s weight are important to this disorder.
5. C. Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm and medicating as needed.
6. B. Delusion of grandeur is a false belief that one is highly famous and important.
7. D. Individual with dependent personality disorder typically shows indecisiveness submissiveness and clinging behavior so that others will make decisions with them.
8. A. Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts.
9. B. Bulimia disorder generally is a maladaptive coping response to stress and underlying issues. The client should identify anxiety causing situation that stimulate the bulimic behavior and then learn new ways of coping with the anxiety.
10. A. An adult age 31 to 45 generates new level of awareness.
11. A. Neuromuscular Blocker, such as SUCCINYLCHOLINE (Anectine) produces respiratory depression because it inhibits contractions of respiratory muscles.
12. C. With depression, there is little or no emotional involvement therefore little alteration in affect.
13. D. These clients often hide food or force vomiting; therefore they must be carefully monitored.
14. A. These clients have severely depleted levels of sodium and potassium because of their starvation diet and energy expenditure, these electrolytes are necessary for cardiac functioning.
15. B. Limiting unnecessary interaction will decrease stimulation and agitation.
16. C. Ritualistic behavior seen in this disorder is aimed at controlling guilt and inadequacy by maintaining an absolute set pattern of behavior.
17. D. The nurse needs to set limits in the client’s manipulative behavior to help the client control dysfunctional behavior. A consistent approach by the staff is necessary to decrease manipulation.
18. B. Any suicidal statement must be assessed by the nurse. The nurse should discuss the client’s statement with her to determine its meaning in terms of suicide.
19. A. When the staff member ask the client if he wonders why others find him repulsive, the client is likely to feel defensive because the question is belittling. The natural tendency is to counterattack the threat to self image.
20. B. The nurse would specifically use supportive confrontation with the client to point out discrepancies between what the client states and what actually exists to increase responsibility for self.
21. C. The nurse would most likely administer benzodiazepine, such as lorazepan (ativan) to the client who is experiencing symptom: The client’s experiences symptoms of withdrawal because of the rebound phenomenon when the sedation of the CNS from alcohol begins to decrease.
22. D. Regular coffee contains caffeine which acts as psychomotor stimulants and leads to feelings of anxiety and agitation. Serving coffee top the client may add to tremors or wakefulness.
23. D. Vomiting and diarrhea are usually the late signs of heroin withdrawal, along with muscle spasm, fever, nausea, repetitive, abdominal cramps and backache.
24. D. Moving to a client’s personal space increases the feeling of threat, which increases anxiety.
25. A. Environmental (MILIEU) therapy aims at having everything in the client’s surrounding area toward helping the client.
26. C. Children who have experienced attachment difficulties with primary caregiver are not able to trust others and therefore relate superficially
27. A. Children have difficulty verbally expressing their feelings, acting out behavior, such as temper tantrums, may indicate underlying depression.
28. D. The autistic child repeat sounds or words spoken by others.
29. D. The client statement is an example of the use of denial, a defense that blocks problem by unconscious refusing to admit they exist.
30. A. Discussion of the feared object triggers an emotional response to the object.
31. B. The nurse presence may provide the client with support & feeling of control.
32. D. Experiencing the actual trauma in dreams or flashback is the major symptom that distinguishes post traumatic stress disorder from other anxiety disorder.
33. C. Confabulation or the filling in of memory gaps with imaginary facts is a defense mechanism used by people experiencing memory deficits.
34. A. These are the major signs of anorexia nervosa. Weight loss is excessive (15% of expected weight).
35. C. Dental enamel erosion occurs from repeated self-induced vomiting.
36. B. Depression usually is both emotional & physical. A simple daily routine is the best, least stressful and least anxiety producing.
37. D. The expression of these feeling may indicate that this client is unable to continue the struggle of life.
38. A. Structure tends to decrease agitation and anxiety and to increase the client’s feeling of security.
39. B. The rituals used by a client with obsessive compulsive disorder help control the anxiety level by maintaining a set pattern of action.
40. C. A person with this disorder would not have adequate self-boundaries.
41. D. Loose associations are thoughts that are presented without the logical connections usually necessary for the listening to interpret the message.
42. C. Helping the client to develop feeling of self worth would reduce the client’s need to use pathologic defenses.
43. B. Open ended questions and silence are strategies used to encourage clients to discuss their problem in descriptive manner.
44. C. Clients who are withdrawn may be immobile and mute, and require consistent, repeated interventions. Communication with withdrawn clients requires much patience from the nurse. The nurse facilitates communication with the client by sitting in silence, asking open-ended question and pausing to provide opportunities for the client to respond.
45. D. When hallucination is present, the nurse should reinforce reality with the client.
46. A. Personal characteristics of abuser include low self-esteem, immaturity, dependence, insecurity and jealousy.
47. D. A short acting skeletal muscle relaxant such as succinylcholine (Anectine) is administered during this procedure to prevent injuries during seizure.
48. C. Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus.
49. D. Electroconvulsive therapy is an effective treatment for depression that has not responded to medication.
50. B. In an emergency, lives saving facts are obtained first. The name and the amount of medication ingested are of outmost important in treating this potentially life threatening situation.