1. A 17-year-old client has a record of being absent in the class without permission, 6.

6. A 16-year-old girl was diagnosed with anorexia. What would be the first
and “borrowing” other people’s things without asking permission. The client denies assessment of the nurse?
stealing; rationalizing instead that as long as no one was using the items, there is no
problem to use it by other people. It is important for the nurse to understand that A. What food she likes.
psychodynamically, the behavior of the client may be largely attributed to a B. Her desired weight.
development defect related to the: C. Her body image.
D. What causes her behavior.
A. Oedipal complex 7. On an adolescent unit, a nurse caring to a client was informed that her client’s
B. Superego closest roommate dies at night. What would be the most appropriate nursing action?
C. Id
D. Ego A. Do not bring it up unless the client asks.
2. A client tells the nurse, “Yesterday, I was planning to kill myself.” What is the best B. Tell the client that her roommate went home.
nursing response to this cient? C. Tell the client, if asked, “You should ask the doctor.”
D. Tell the client that her closest roommate died.
A. “What are you going to do this time?” 8. A woman gave birth to an unhealthy infant, and with some body defects. The nurse
B. Say nothing. Wait for the client’s next comment should expect the woman’s initial reactions to include:
C. “You seem upset. I am going to be here with you; perhaps you will want to talk about
it” A. Depression
D. “Have you felt this way before?” B. Withdrawal
3. In crisis intervention therapy, which of the following principle that the nurse will C. Apathy
use to plan her/his goals? D. Anger
9. A client in the psychiatric unit is shouting out loud and tells the nurse, “Please, help
A. Crises are related to deep, underlying problems me. They are coming to get me.” What would be the appropriate nursing response?
B. Crises seldom occur in normal people’s lives
C. Crises may go on indefinitely. A. “ I won’t let anyone get you.”
D. Crises usually resolved in 4-6 weeks. B. “Who are they?”
4. The nurse enters the room of the male client and found out that the client urinates C. “I don’t see anyone coming.”
on the floor. The client hides when the nurse is about to talk to him. Which of the D. “You look frightened.”
following is the best nursing intervention? 10. A client who is severely obese tells the nurse, “My therapist told me that I eat a
lot because I didn’t get any attention and love from my mother. What does the
A. Place restriction on the client’s activities when his behavior occurs. therapist mean?” What is the best nursing response?
B. Ask the client to clean the soiled floor.
C. Take the client to the bathroom at regular intervals. A. “What do you think is the connection between your not getting enough love and
D. Limit fluid intake. overeating?”
5. A young lady with a diagnosis of schizophrenic reaction is admitted to the B. “Tell me what you think the therapist means.”
psychiatric unit. In the past two months, the client has poor appetite, experienced C. “You need to ask your therapist.”
difficulty in sleeping, was mute for long periods of time, just stayed in her room, D. “ We are here to deal with your diet, not with your psychological problems.”
grinning and pointing at things. What would be the initial nursing action on admitting 11. After the discussion about the procedure the physician scheduled the client for
the client to the unit? mastectomy. The client tells the nurse, “If my breasts will be removed, I’m afraid my
husband will not love me anymore and maybe he will never touch me.” What should
A. Assure the client that “ You will be well cared for.” the nurse’s response?
B. Introduce the client to some of the other clients.
C. Ask “Do you know where you are?” A. “I doubt that he feels that way.”
D. Take the client to the assigned room. B. “What makes you feel that way?”
C. “Have you discussed your feelings with your husband?”
D. Ask the husband, in front of the wife, how he feels about this.
 12. The child is brought to the hospital by the parents. During assessment of the 17. A male client is quiet when the physician told him that he has stage IV cancer and
nurse, what parental behavior toward a child should alert the nurse to suspect child has 4 months to live. The nurse determines that this reaction may be an example of:
abuse?
A. Indifference
A. Ignoring the child. B. Denial
B. Flat affect. C. Resignation
C. Expressions of guilt. D. Anger
D. Acting overly solicitous toward the child 18. A nurse is caring to a female client with five young children. The family member
13. A nurse is caring to a client with manic disorder in the psychiatric ward. On the told the client that her ex-husband has died 2 days ago. The reaction of the client is
morning shift, the nurse is talking with the client who is now exhibiting a manic stunned silence, followed by anger that the ex-husband left no insurance money for
episode with flight of ideas. The nurse primarily needs to: their young children. The nurse should understand that:

A. Focus on the feelings conveyed rather than the thoughts expressed. A. The children and the injustice done to them by their father’s death are the woman’s
B. Speak loudly and rapidly to keep the client’s attention, because the client is easily main concern.
distracted. B. To explain the woman’s reaction, the nurse needs more information about the
C. Allow the client to talk freely. relationship and breakup.
D. Encourage the client to complete one thought at a time. C. The woman is not reacting normally to the news.
14. The nurse is caring to an autistic child. Which of the following play behavior would D. The woman is experiencing a normal bereavement reaction.
the nurse expect to see in a child? 19. A client who is manic comes to the outpatient department. The nurse is assigning
an activity for the client. What activity is best for the nurse to encourage for a client in
A. competitive play a manic phase?
B. nonverbal play
C. cooperative play A. Solitary activity, such as walking with the nurse, to decrease stimulation.
D. solitary play B. Competitive activity, such as bingo, to increase the client’s self-esteem.
15. The client is telling the nurse in the psychiatric ward, “I hate them.” Which of the C. Group activity, such as basketball, to decrease isolation.
following is the most appropriate nursing response to the client? D. Intellectual activity, such as scrabble, to increase concentration.
20. The nurse is about to administer Imipramine HCI (Tofranil) to the client, the client
A. “Tell me about your hate.” says, “Why should I take this?” The doctor started me on this 10days ago; it didn’t
B. “I will stay with you as long as you feel this way.” help me at all.” Which of the following is the best nursing response:
C. “For whom do you have these feelings?”
D. “I understand how you can feel this way.” A. “What were you expecting to happen?”
16. The mother visits her son with major depression in the psychiatric unit. After the B. “It usually takes 2-3 weeks to be effective.”
conversation of the client and the mother, the nurse asks the mother how it is talking C. “Do you want to refuse this medication? You have the right.”
to her son. The mother tells the nurse that it was a stressful time. During an interview D. “That’s a long time wait when you feel so depressed.”
with the client, the client says, “we had a marvelous visit.” Which of the following 21. Which of the following drugs the nurse should choose to administer to a client to
coping mechanism can be described to thestatement of the client? prevent pseudoparkinsonism?

A. Identification. A. Isocarboxazid (Marplan)

B. Rationalization. B. Chlorpromazine HCI (Thorazine)
C. Denial. C. Trihexyphenidyl HCI (Artane)
D. Compensation. D. Trifluoperazine HCI (Stelazine)
 22. The nurse is caring to an 80-year-old client with dementia? What is the most 27. A male client diagnosed with depression tells the nurse, “I don’t want to look
important psychosocial need for this client? weak and I don’t even cry because my wife and my kids can’t bear it.” The nurse
understands that this is an example of:
A. Focus on the there-and-then rather the here-and-now.
B. Limit in the number of visitors, to minimize confusion. A. Repression.
C. Variety in their daily life, to decrease depression. B. Suppression.
D. A structured environment, to minimize regressive behaviors. C. Undoing.
23. A client tells the nurse, “I don’t want to eat any meals offered in this hospital D. Rationalization.
because the food is poisoned.” The nurse is aware that the client is expressing an 28. A female client tells the nurse that she is afraid to go out from her room because
example of: she thinks that the other client might kill her. The nurse is aware that this behavior is
related to:
A. Delusion.
B. Hallucination. A. Hallucination.
C. Negativism. B. Ideas of reference.
D. Illusion. C. Delusion of persecution.
24. A client is admitted in the hospital. On assessment, the nurse found out that the D. Illusion.
client had several suicidal attempts. Which of the following is the most important 29. A female client is taking Imipramine HCI (Tofranil) for almost 1 week and shows
nursing action? less awareness of the physical body. What problem would the nurse be most
concerned?
A. Ignore the client as long as he or she is talking about suicide, because suicide attempt
is unlikely. A. Nausea.
B. Administer medication. B. Gait disturbances.
C. Relax vigilance when the client seems to be recovering from depression. C. Bowel movements.
D. Maintain constant awareness of the client’s whereabouts. D. Voiding.
25. The nurse suspects that the client is suffering from depression. During 30. A 6-year-old client dies in the nursing unit. The parents want to see the child.
assessment, what are the most characteristic signs and symptoms of depression the What is the most appropriate nursing action?
nurse would note?
A. Give the parents time alone with the body.
A. Constipation, increased appetite. B. Ask the physician for permission.
B. Anorexia, insomnia. C. Complete the postmortem care and quietly accompany the family to the child’s room.
C. Diarrhea, anger. D. Suggest the parents to wait until the funeral service to say “good-bye.”
D. Verbosity, increased social interaction. 31. A 20-year-old female client is diagnosed with anxiety disorder. The physician
26. The client in the psychiatric unit states that, “The goodas are coming! I must be prescribed Flouxetine (Prozac). What is the most important side effects should a nurse
ready.” In response to this neologism, the nurse’s initial response is to: be concerned?

A. Acknowledge that the word has some special meaning for the client. A. Tremor, drowsiness.
B. Try to interpret what the client means. B. Seizures, suicidal tendencies.
C. Divert the client’s attention to an aspect of reality. C. Visual disturbance, headache.
D. State that what the client is saying has not been understood and then divert attention D. Excessive diaphoresis, diarrhea.
to something that is really bound. 32. A nurse is assigned to activate a client who is withdrawn, hears voices and
negativistic. What would be the best nursing approach?

A. Mention that the “voices” would want the client to participate.

B. Demand that the client must join a group activity.
C. Give the client a long explanation of the benefits of activity.
D. Tell the client that the nurse needs a partner for an activity.
 33. A nurse is going to give a rectal suppository as a preoperative medication to a 4- 38. Which of the following person will be at highest risk for suicide?
year-old boy. The boy is very anxious and frightened. Which of the following
statement by the nurse would be most appropriate to gain the child’s cooperation? A. A student at exam time
B. A married woman, age 40, with 6 children.
A. “Be a big kid! Everyone’s waiting for you.” C. A person who is an alcoholic.
B. “Lie still now and I’ll let you have one of your presents before you even have your D. A person who made a previous suicide attempt.
operation.” 39. A male client is repetitively doing the handwashing every time he touches things.
C. “Take a nice, big, deep breath and then let me hear you count to five.” It is important for a nurse to understand that the client’s behavior is probably an
D. “You look so scared. Want to know a secret? This won’t hurt a bit!” attempt to:
34. A depressed client is on an MAO inhibitor? What should the nurse watch out for?
A. Seek attention from the staff.
A. Hypertensive crisis. B. Control unacceptable impulses or feelings.
B. Diet restrictions. C. Do what the voices the patient hears tell him or her to do.
C. Taking medication with meals. D. Punish himself or herself for guilt feeling.
D. Exposure to sunlight. 40. In a mental health settings, the basic goal of nursing is to:
35. A 16-year-old girl is admitted for treatment of a fracture. The client shares to the
nurse caring to her that her step-father has made sexual advances to her. She got the A. Advance the science of psychiatry by initiating research and gathering data for current
chance to tell it to her mother but refuses to believe. What is the most therapeutic statistics on emotional illness.
action of the nurse would be: B. Plan activity programs for clients.
C. Understand various types of family therapy and psychological tests and how to
A. Tell the client to work it out with her father. interpret them.
B. Tell the client to discuss it with her mother. D. Maintain a therapeutic environment.
C. Ask the father about it. 41. A 3-year-old boy is brought to the emergency department. After an hour, the boy
D. Ask the mother what she thinks. dies of respiratory failure. The mother of the boy becomes upset, shouting and
36. A client with a diagnosis of paranoid disorder is admitted in the psychiatric abusive, saying to the nurse, “If it had been your son, they would have done more to
hospital. The client tells the nurse, “the FBI is following me. These people are plotting save it. “What should the nurse say or do?
against me.” With this statement the nurse will need to:
A. Touch her and tell her exactly what was done for her baby.
A. Acknowledge that this is the client’s belief but not the nurse’s belief. B. Allow the mother to continue her present behavior while sitting quietly with her.
B. Ask how that makes the client feel. C. “No, all clients are given the same good care.”
C. Show the client that no one is behind. D. “Yes, you’re probably right. Your son did not get better care.”
D. Use logic to help the client doubt this belief. 42. The nurse is interacting to a client with an antisocial personality disorder. What
37. A nurse is completing the routine physical examination to a healthy 16-year-old would be the most therapeutic approach of the nurse to an antisocial behavior?
male client. The client shares to the nurse that he feels like killing his girlfriend
because he found out that her girlfriend had another boyfriend. He then laughs, and A. Gratify the client’s inner needs.
asks the nurse to keep this a secret just between the two of them. The nurse reviews B. Give the client opportunities to test reality.
his chart and notes that there is no previously history of violence or psychiatric illness. C. Provide external controls.
Which of the following would be the best action of the nurse to take at this time? D. Reinforce the client’s self-concept.

A. Suggest the teen meet with a counselor to discuss his feelings about his girlfriend.
B. Tell the teen that his feelings are normal, and recommend that he find another
girlfriend to take his mind off the problem.
C. Recall the teenage boys often say things they really do not mean and ignore the
comment.
D. Regard the comment seriously and notify the teen’s primary health care provider and
parents
 43. A 55-year-old male client tells the nurse that he needs his glasses and hearing aid 48. A female client was diagnosed with breast cancer. It is found to be stage IV, and
with him in the recovery room after the surgery, or he will be upset for not granting a modified mastectomy is performed. After the procedure, what behaviors could the
his request. What is the appropriate nursing response? nurse expects the client to display?

A. “Do you get upset and confused often?” A. Denial of the possibility of carcinoma.
B. “You won’t need your glasses or hearing aid. The nurses will take care of you.” B. Signs of grief reaction.
C. “I understand. You will be able to cooperate best if you know what is going on, so I C. Relief that the operation is over.
will find out how I can arrange to have your glasses and hearing aid available to you D. Signs of deep depression.
in the recovery room.” 49. A client is withdrawn and does not want to interact to anybody even to the nurse.
D. I understand you might be more cooperative if you have your aid and glasses, but What is the best initial nursing approach to encourage communication with this client?
that is just not possible. Rules, you know.”
44. The male client had fight with his roommates in the psychiatric unit. The client A. Use simple questions that call for a response.
agitated client is placed in isolation for seclusion. The nurse knows it is essential that: B. Encourage discussion of feelings.
C. Look through a photo album together.
A. A staff member has frequent contacts with the client. D. Bring up neutral topics.
B. Restraints are applied. 50. Which of the following nursing approach is most important in a client with
C. The client is allowed to come out after 4 hours. depression?
D. All the furniture is removed from the isolation room.
45. A medical representative comes to the hospital unit for the promotion of a new A. Deemphasizing preoccupation with elimination, nourishment, and sleep.
product. A female client, admitted for hysterical behavior, is found embracing him. B. Protecting against harm to others.
What should the nurse say? C. Providing motor outlets for aggressive, hostile feelings.
D. Reducing interpersonal contacts.
A. “Have you considered birth control?”
B. “This isn’t the purpose of either of you being here.”
C. “I see you’ve made a new friend.”
D. “Think about what you are doing.”
46. A client with dementia is for discharge. The nurse is providing a discharge
instruction to the family member regarding safety measures at home. What
suggestion can the nurse make to the family members?

A. Avoid stairs without banisters.

B. Use restraints while the client is in bed to keep him or her from wandering off during
the night.
C. Use restraints while the client is sitting in a chair to keep him or her from wandering
off during the day.
D. Provide a night-light and a big clock.
47. A 30-year-old married woman comes to the hospital for treatment of fractures.
The woman tells the nurse that she was physically abused by her husband. The
woman receives a call from her husband telling her to get home and things will be
different. He felt sorry of what he did. What can the nurse advise her?

A. “Do you think so?”

B. “It’s not likely.”
C. “What will be different?”
D. “I hope so, for your sake.”
 Answers and Rationales
1. B. This shows a weak sense of moral consciousness. According to Freudian theory,
personality disorders stem from a weak superego.
2. C. The client needs to have his or her feelings acknowledged, with encouragement to
discuss feelings, and be reassured about the nurse’s presence.
3. D. Part of the definition of a crisis is a time span of 4-6 weeks.
4. C. The client is most likely confused, rather than exhibiting acting-out, hostile
behavior. Frequent toileting will allow urination in an appropriate place.
5. D. The client needs basic, simple orientation that directly relates to the here-and-now,
and does not require verbal interaction.
6. A. Although all options may appear correct. A is the best because it focuses on a
range of possible positive reinforcers, a basis for an effective behavior modification
program. It can lead to concrete, specific nursing interventions right away and
provides a therapeutic use of “control” for the 16-year-old.
7. A. The nurse needs to wait and see: do not “jump the gun”; do not assume that the
client wants to know now.
8. D. The woman is experiencing an actual loss and will probably exhibit many of the
same symptoms as a person who has lost someone to death.
9. C. This option is an example of pointing out reality- the nurse’s perception.
10. B. This response asks information that the nurse can use. If the client understands
the statement, the nurse can support the therapist when focusing on connection
between food, love, and mother. If the client does not understand thestatement, the
nurse can help get clarification from the therapist.
11. C. This option redirects the client to talk to her husband.
12. D. This is an example of reaction formation, a coping mechanism.
13. A. Often the verbalized ideas are jumbled, but the underlying feelings are discernible
and must be acknowledged.
14. D. Autistic children do best with solitary play because they typically do not interact
with others in a socially comprehensible and acceptable way.
15. A. The nurse is asking the client to clarify and further discuss feelings.
16. C. Denial is the act of avoiding disagreeable realities by ignoring them.
17. B. Reactions when told of a life-threatening illness stem from Kübler-Ross’ ideas on
death and dying. Denial is a typical grief response, and usually is a first reaction.
18. D. Shock and anger are commonly the primary initial reactions.
19. A. This option avoids external stimuli, yet channels the excess motor activity that is
often part of the manic phase.
20. B. The patient needs a brief, factual answer.
21. C. Trihexyphenidyl HCI (Artane) is often used to counteract side effect of
pseudoparkinsonism, which often accompanies the use of phenothiazine, such as
chlorpromazine HCI (Thorazine or Trifluoperazine HCI (Stelazine).
22. D. Persons with dementia needs sameness, consistency, structure, routine, and
predictability.
23. A. This is a false belief developed in response to an emotional need.
24. D. The client must be constantly observed.
25. B. The appetite is diminished and sleeping is affected to a client with depression.
26. A. It is important to acknowledge a statement, even if it is not understood.
27. D. Rationalization is the process of constructing plausible reasons for one’s responses.
28. C. The client has ideas that someone is out to kill her.
29. D. A serious side effect of Imipramine HCI (Tofranil) is urinary retention (voiding
problems)
30. A. This allows the parents/family to grieve over the loss of the child, by going through
the steps of leave taking.
31. B. Assess for suicidal tendencies, especially during early therapy. There is an
increased risk of seizures in debilitated client and those with a history of seizures.
32. D. The nurse helps to activate by doing something with the client.
33. C. Preschool children commonly experience fears and fantasies regarding invasive
procedures. The nurse should attempts to momentarily distract the child with a simple
task that can be easily accomplished while the child remains in the side-lying position.
The suppository can be slipped into place while the child is counting, and then the
nurse can praise the child for cooperating, while holding the buttocks together to
prevent expulsion of the suppository.
34. A. This is the more inclusive answer, although diet restrictions (answer1) are
important, their purpose is to prevent hypertensive crisis (answer 2).
35. D. This comes closest to beginning to focus on family-centered approach to intervene
in the “conspiracy of silence”. This is therefore the best among the options.
36. A. The nurse should neither challenge nor use logic to dispel an irrational belief.
37. D. Any threat to the safety of oneself or other should always be taken seriously and
never disregarded by the nurse.
38. C. The likelihood of multiple contributing factors may make this person at higher risk
for suicide. Some factors that may exist are physical illness related to alcoholism,
emotional factors ( anxiety, guilt, remorse), social isolation due to impaired
relationships and economic problems related to employment.
39. B. A ritual, such as compulsive handwashing, is an attempt to allay anxiety caused by
unconscious impulses that are frightening.
40. D. This is the most neutral answer by process of elimination.
41. B. This option allows a normal grief response (anger).
42. C. Personality disorders stem from a weak superego, implying a lack of adequate
controls.
43. C. The client will be easier to care for if he has his hearing aid and glasses.
44. A. Frequent contacts at times of stress are important, especially when a client is
isolated.
45. B. This response is aimed at redirecting the inappropriate behavior.
46. D. This option is best to decrease confusion and disorientation to place and time.
47. C. This option helps the woman to think through and elaborate on her own thoughts
and prognosis.
48. B. It is mostly likely that grief would be expressed because of object loss.
49. D. Neutral, nonthreatening topics are best in attempting to encourage a response.
50. C. It is important to externalize the anger away from self.