60. A client is in a withdrawn catatonic state and exhibits waxy flexibility.

During the initial phase of

hospitalization for this client, the nurse’s first priority is to:
A. Watch for edema and cyanosis of the extremities
B. Encourage the client to discuss concerns that led to the catatonic state
C. Provide a warm, nurturing relationship, with therapeutic use of touch
D. Identify the predisposing factors in the illness

Circulation may be severely impaired in a client with waxy flexibility who tends to remain motionless for
hours unless moved

61. During the initial interview with a client, the client begins to feel uncomfortable and realizes the nurse’s
behaviors and mannerisms remind the client of her abusive mother. The nurse realizes this phenomena is
known as:
A. Transference
B. Countertransference
C. Reaction formation
D. Self-awareness

Transference is the unconscious process of displaying feelings for significant people in the past onto the
nurse in the present relationship
Countertransference is the nurse’s emotional reaction to clients based on feelings for significant people in
the nurse’s past
Reaction formation is a defense mechanism that causes people to act exactly opposite to the way they
feel

62. In paranoid disorder, the part of the personality that is weak is called the:
A. Id
B. Ego
C. Superego
D. “Not me”

A diagnosis of paranoid disorder implies a weak ego development

63. An important part of the nursing care for a client with dementia would be:
A. Minimizing regression
B. Correcting memory loss
C. Rehabilitating toward independent functioning
D. Preventing further deterioration

Main goal is to prevent the further loss of cognition that is why regression should be minimized

64. What are the most significant signs and symptoms indicative of delirium tremens (alcohol withdrawal
delirium)?
A. Decreased BP and pulse, restlessness
B. Increased BP and pulse, seizures
C. Cramps, nausea, vomiting
D. Anorexia, diarrhea, dehydration

65. To relate therapeutically with a client who is independent on alcohol, it is important that the nurse
base care on the understanding that alcohol independence:
A. Is hereditary
B. Is due to lack of willpower and true remorse
C. Results in always breaking promises
D. Cannot be cured
66. A client uses repetitive hand washing. To help the client use less maladaptive means of handling
stress, the nurse could:
A. Provide varied activities on the unit, because change in routine can break this ritualistic pattern.
B. Give the client unit assignments that do not require perfection
C. Tell the client of changes in routine at the last minute to avoid buildup of anxiety
D. Provide an activity in which positive accomplishment can occur so the client can gain recognition

67. The most common defense mechanism used in somatoform disorders are:
A. Repression and symbolism
B. Sublimation and regression
C. Substitution and displacement
D. Reaction formation and rationalization

The original source of conflict, pain, or guilt is repressed, only to surface in a symbolic way.

68. A client is diagnosed as having a paranoid disorder. What implication might this have on the nurse?
A. Let the client talk about the suspicions without correcting misinformation
B. Avoid talking to other nurses when the client can see them but cannot hear what is being said
C. Placate the client by agreeing with what he or she says.
D. Argue with the client about his or her ideas

A client with paranoid disorder is suspicious, so a nurse must make every effort not to engage in behavior
the client can misinterpret

69. Which is an example of limit setting as an effective nursing intervention in ritualistic hand-washing
behavior?
A. “I don’t want you to wash your hand so often anymore”
B. “If you continue to wash your hands so frequently, the skin on your hands will break down.”
C. “You may wash your hands before the group therapy meeting if you wish, but not during group
therapy.”
D. “The doctor wrote an order that you are to stop washing your hands so often.”

This is the best example of limit setting on behavior

70. Which nursing intervention is effective when clients are severely anxious?
A. Encourage group participation
B. Give detailed instructions before treatment procedures
C. Impart information succinctly and concretely
D. Increase opportunities for decision making

Brief and specific information should be given in a person with severe anxiety

71. A nursing care plan for a client with a history of alcohol abuse and dependency must incorporate
monitoring which physical consequence?
A. Cardiac arrhythmia
B. Convulsive disorder
C. Psychomotor hyperactivity
D. Cirrhosis of the liver

The liver is affected both by direct effect of alcohol and the nutritional deficiencies associated with alcohol
abuse

72. When assessing clients who are exhibiting a depressed episode and those who are exhibiting a manic
episode of bipolar mood disorders, which characteristic common to both episodes of the disorder is the
nurse likely to note?
 A. Suicidal tendency
B. Underlying hostility
C. Delusions
D. Flight of ideas

In the depressed episode, anger is turned inward; in the manic, it is noted in sarcasm, demanding
behavior, and angry outbursts
A – occurs in depressed phase
C & D – occur in manic episode

73. In working with clients who are depressed, the nurse must know that depression may stem from::
A. A sense of loss – actual, imaginary, or impending
B. Revived memories of a painful childhood
C. A confused sexual identity
D. An unresolved oedipal conflict

Loss is the most basic cause of the development of depression

74. Which activity would be best for the nurse to suggest to a client who is depressed?
A. Folding laundry or stapling paper sheets for charts
B. Playing chess
C. Doing a crossword puzzle
D. Joining a 5K marathon fun run

An undemanding task that the client could finish would allow a feeling of successful accomplishment
B & C requires intellectual activity, which is usually slowed down during a depressive phase
D – client may not have the psychomotor energy to run or jog

75. Which activity could a nurse suggest that would be best for a client with hyperactive behavior?
A. Solitary activity, such as reading
B. Hammering on metal in a jewelry-making class
C. Playing chess
D. Playing basketball

It will provide energy release without the external stimuli and pressure of competitive games
Reading usually requires sitting, which a client who is hyperactive cannot readily do

76. In explaining the goal of therapy in crisis intervention to a new colleague, the shieldster nurse states
that the goal is to?
A. Restructure the personality
B. Desensitization
C. Remove anxiety
D. Resolve immediate problems

The major goal of crisis intervention is to resolve immediate problems

A – goal of psychoanalytic therapy
B – goal for phobia
C – goal for anxiety disorders

77. A client with antisocial behavior flatters the nurse. What is the client trying to do?
A. The client wants something in return
B. The client wants the nurse to like him
C. The client needs attention
D. The client is trying to redirect the focus of the nurse-client interaction
Manipulation is a characteristic of antisocial behavior to get the client’s own wants whatever it may be

78. In admitting a client with Alzheimer’s to the unit, which placement variable would have the highest
priority?
A. Place the client with a roommate
B. Place the client without a roommate
C. Place the client close to the nurse’s station
D. Place the client at a distance from the nurses’ station

Nursing observation is easier if the client is nearby.

Nursing observation is the priority for a client with memory problems and confusion for safety risks

79. A client hospitalized with Alzheimer’s disease is often found wandering in the streets. What
measure(s) should be taken in the unit to prevent the client form wandering off?
A. Place the client in daytime restraints
B. Place the client in nighttime restraints
C. Provide a security guard at the door
D. Use electronic surveillance devices

This answer is concerned with accident prevention and is a means of observation of the client. Restraints
should not be used.
Having a security guard is not realistic

80. A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client
is very upset and tells the nurse, “This is all the doctor’s fault. I have done everything that the doctor has
asked me to do!” The nurse interprets the client’s statement as:
A. An expected coping mechanism
B. A need to notify the hospital lawyer
C. An expression of guilt on the part of the client
D. An ineffective coping mechanism

The nurse needs to be aware of the effective and ineffective coping mechanisms that can occur in a client
when loss is anticipated. The expression of anger is known to be a normal response to impending loss,
and the anger may be directed toward the self, God or another spiritual being, or caregivers. Notifying the
hospital lawyer is inappropriate. Guilt may or may not be a component of the client’s feelings, and the
data in the question do not indicate that guilt is present.

81. A client is admitted to a medical nursing unit with a diagnosis of acute blindness. Many tests are
performed, and there seems to be no organic reason why this client cannot see. The client became blind
after witnessing a hit-and-run car accident, when a family of three was killed. A nurse suspects that the
client may be experiencing a:
A. Psychosis
B. Repression
C. Conversion disorder
D. Dissociative disorder

A conversion disorder is the alteration or loss of a physical function that cannot be explained by any
known pathophysiological mechanism.
A conversion disorder is thought to be an expression of a psychological need or conflict. In this situation,
the client witnessed an accident that was so psychologically painful that the client became blind.
A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity,
memory, or consciousness.
Psychosis is a state in which a person’s mental capacity to recognize reality, communicate, and relate to
others is impaired, interfering with the person’s ability to deal with life’s demands.
Repression is a coping mechanism in which unacceptable feelings are kept out of awareness.
82. Which of the following is the best approach for the nurse to use in crisis counseling?
A. Reassuring
B. Passive listening
C. Explore early life experiences
D. Active, with focus on the current situation

During crisis counseling, the best approach for the nurse to use is an active one, with a focus on the
current situation.
Options A, B, and C would be inconsistent with the acute needs that emerge in a crisis. Passive listening
would be contrary to the individual’s acute stress and disorganization. Exploring the past would be
insensitive to the current crisis and would be exploitative of a person in acute distress. Although
reassurance may be needed, what is most important about the nurse’s response in a crisis is the need for
a direct focus on immediate needs.

83. The spouse of a client admitted to the mental health unit for alcohol withdrawal says to a nurse, “I
should get out of this bad situation.” The most helpful response by the nurse would be:
A. “Why don’t you tell your husband about this?
B. ‘What do you find difficult about this situation?”
C. “This is not the best time to make that decision.”
D. “I agree with you. You should get out of this situation.”

The most helpful response is one that encourages the client to solve problems.
Giving advice implies that the nurse knows what is best and can foster dependency.
The nurse should not agree with the client, and the nurse should not request that the client provide
explanations.

84. The nurse has been working with a victim of rape in a clinic setting for the past 4 weeks. Which of the
following would be unrealistic as a short-term initial goal for this client?
A. Physical wounds will heal
B. The client will participate in the treatment plan
C. The client will verbalize feelings about the event
D. The client will resolve feelings of fear and anxiety related to the rape trauma

Short-term goals include the beginning stages of dealing with the rape trauma. Clients will be expected
initially to keep appointments, participate in care, begin to explore feelings, and begin to heal any physical
wounds that were inflicted at the time of the rape.
Option 4 is a long-term goal.

85. A night nurse reported to the nurse manager that a client was admitted to the mental health unit after
attacking his father with an iron for interrupting him at his computer. During nursing rounds, the client
interrupts the nurse manager and says, “I need to get out of here so I can work on my computer project to
save the world!” Which of the following is a therapeutic response by the nurse manager?
A. “I will be able to talk with you in 15 minutes after I complete nursing rounds.”
B. “You have a project to save the world? I’d really like to hear about that after I finish rounds.”
C. ‘Well, sit right down and eat your breakfast. You’re not going to save the world on an empty
stomach.”
D. “You hurt your father because of these thoughts and you won’t leave here until you can control
yourself better.”

The therapeutic response is one that sets limits on the client’s interruptive behavior and assesses the
client’s ability to control his behavior.
In option B the nurse uses restating and feeds into the client’s delusional system, which is not therapeutic
and belittles the client.
In option C the nurse uses a “playful and mothering” type of social response, which may escalate the
client’s behavior.
In option D the nurse chastises the client for behavior that is not within the client’s control.