3.

After completing chemical detoxification and a 12-step program to treat crack addiction, a male patient is being prepared for discharge. Which remark by the patient indicates a realistic view of the future? a. Im never going to use crack again. b. I know what I have to do. I have to limit my crack use. c. Im going to take 1 day at a time. Im not making any promises. d. I cant touch crack again, but I sure could use a drink. Ive earned it. 4. The nurse formulates a nursing diagnosis of impaired verbal communication for a male patient with schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention is most appropriate? a. Helping the patient to participate in social interactions b. Establishing a one-on-one relationship with the patient c. Establishing alternative forms of communication d. Allowing the patient to decide when he wants to participate in verbal communication with you 5. A female patient with obsessive-compulsive disorder tells the nurse that he must check the lock on his apartment door 25 times before leaving for an appointment. The nurse knows that this behavior represents the patients attempt to: a. Call attention to himself b. Control his thoughts c. Maintain the safety of his home d. Reduce anxiety 6. A patient, age 42, is admitted for surgical biopsy of a suspicious lump in her left breast. When the nurse comes to her surgery, she is tearfully finishing a letter to her children. She tells the nurse, I want to leave this for my children in case anything goes wrong today. Which response by the nurse would be most therapeutic? a. In case anything goes wrong? What are your thoughts and feelings right now? b. I cant understand that youre nervous, but this is really a minor procedure. Youll be back in your room before you know it.

c. Try to take a few deep breaths and relax. I have some medication that will help. d. Im sure your children know how much you love them. Youll be able to talk to them on the phone in a few hours. 7. Which nursing intervention is most important when restraining a violent male patient? a. Reviewing hospital policy regarding how long the patient can be restrained b. Preparing a p.r.n. dose of the patients psychotropic medication c. Checking that the restraints have been applied correctly d. Asking if the patient needs to use the bathroom or is thirsty 8. How soon after chlorpromazine administration should the nurse in charge expect to see a patients delusion thoughts and hallucinations eliminated? a. Several minutes b. Several hours c. Several days d. Several weeks 9. Mental health laws in each state specify when restraints can be used and which type of restraints are allowed. Most laws stipulate that restraints can be used: a. For a maximum of 2 hours b. As necessary to control the patient c. If the patient poses a present danger to self or others d. Only with the patients consent 10. A female patient has been severely depressed since her husband died 6 months ago. Her doctor prescribes amitriptyline hydrochloride (Elavil), 50 mg P.O. daily. Before administering amitriptyline, the nurse reviews the patients medical history. Which preexisting condition would require cautions use of this drug? a. Hiatal hernia b. Hypernatremia

c. Hepatic disease d. Hypokalemia 11. The physician orders a new medication for a male client with generalized anxiety disorder. During medication teaching, which statement or question by the nurse would be most appropriate? a. Take this medication. It will reduce your anxiety. b. Do you have any concern about taking the medication? c. Trust us. This medication has helped many people. We wouldnt have you take it if it were dangerous. d. How can we help you if you wont cooperate? 12. The nurse is aware that the Hormonal effects of the antipsychotic medications include which of the following? a. Retrograde ejaculation and gynecomastia b. Dysmenorrhea and increased vaginal bleeding c. Polydipsia and dysmenorrheal d. Akinesia and dysphasia 13. The nurse is caring for a female client in the manic phase of bipolar disorder whos ready for discharge from the psychiatric unit. As the nurse begins to terminate the nurse-client relationship, which client response is most appropriate? a. Expressing feeling of anxiety b. Displaying anger, shouting, and banging the table c. Withdrawing from the nurse in silence d. Rationalizing the termination, saying that everything comes to an end 14. The nurse is caring for a male client with schizophrenia. Which outcome is the least desirable? a. The client spends more time by himself b. The client doesnt engage in delusional thinking

c. The client doesnt harm himself or others d. The client demonstrates the ability to meet his own self-care needs 15. The nurse is assigned to care for a recently admitted female client who has attempted suicide. What should the nurse do? a. Search the clients belongings and room carefully for items that could be used to attempt suicide b. Express trust that the client wont cause self-harm while in the facility c. Respect the clients privacy by not searching any belongings d. Remind all staff members to check on the client frequently 16. A male client becomes angry and belligerent toward the nurse after speaking on the phone with his mother. The nurse recognizes this as what defense mechanism? a. Rationalization b. Repression c. Displacement d. Suppression 17. Nursing preparations for a client undergoing electroconvulsive therapy (ECT) resembles those used for: a. Physical therapy b. Neurologic examination c. General anesthesia d. Cardiac stress testing 18. Nursing care for a male client with schizophrenia must be based on valid psychiatric and nursing theories. The nurses interpersonal communication with the client and specific nursing intervention must be: a. Clearly identified with boundaries and specifically defined roles b. Warn and non threatening

c. Centered on clearly defined limits and expression of empathy d. Flexible enough for the nurse to adjust the care plan as the situation warrants 19. Before eating a meal, a female client with obsessive-compulsive disorder (OCD) must wash his hands for 18 minutes, comb his hair 444 strokes, and switch thebathroom lights 44 times. What is the most appropriate goal of care for this client? a. Omit one unacceptable behavior each day b. Increase the clients acceptance of therapeutic drug use c. Allow ample time for the client to complete all rituals before each meal d. Systematically decrease the number of repetitions of rituals and the amount of time spent performing them. 20. A male client with a history of medication noncompliance is receiving outpatient treatment for chronic undifferentiated schizophrenia. The physician is most likely to prescribe which medication for this client? a. Chlorpromazine (Thorazine) b. Imipramine (Tofranil) c. Lithium carbonate (Lithane) d. Fluphenazine decanoate (Prolixin Decanoate) 21. A 23-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely to be evidence of ineffective individual coping? a. In ability to make choices and decisions without advice b. Showing interest only in solitary activities c. Avoiding developing relationship d. Recurrent self-destructive behavior with history of depression 22. During the mental status examination, a female client may be asked to explain such proverbs as Dont cry over spilled milk. The purpose is to evaluate the clients ability to think: a. Rationally b. Concretely

c. Abstractly d. Tangentially 23. After an upsetting divorce, a male client threatens to commit suicide with a handgun and is involuntarily admitted to the psychiatric unit with major depression. Which nursing diagnosis takes highest priority for this client? a. Hopelessness related to recent divorce b. Ineffective coping related to inadequate stress management c. Spiritual distress related to conflicting thoughts about suicide and sin d. Risk for self-directed-violence related to planning to commit suicide with a handgun 24. A 25-year-old man reports losing his sight in both eyes. Hes diagnosed as having conversion disorder and is admitted to the psychiatric unit. Which nursing intervention would be most appropriate for this client? a. Not focusing on his blindness b. Providing self-care for him c. Telling him that his blindness isnt real d. Teaching eye exercises to strengthen his eyes 25. In group therapy, a male client angrily speaks up and responds to a peer, Youre always whining and Im getting tired of listening to you! Here is the worlds smallest violin playing for you. Which role is the client playing? a. Blocker b. Monopolizer c. Recognition seeker d. Aggressor 26. A nurse places a female client in full leather restraints. How often must the nurse check the clients circulation? a. Once per hour b. Once per shift

c. Every 10 to 15 minutes d. Every 2 hours 27. When interviewing the parents of an injured child, which sign is the strongest indicator that child abuse may be a problem? a. The injury isnt consistent with the history of the childs age b. The mother and father tell different stories regarding what happened c. The family is poor d. The parents are argumentative and demanding with emergency department personnel 28. Unhealthy personal boundaries are a product of dysfunctional families and a lack of positive role models. Unhealthy boundaries may also be a result of: a. Structured limit setting b. Supportive environment c. Abuse and neglect d. Direction and attention 29. When monitoring a male client recently admitted for treatment of cocaine addiction, the nurse notes sudden increase in the arterial blood pressure and heart rate. To correct these problems, the nurse expects the physician to prescribe: a. Norepinephrine (Levophed) and lidocaine (Xylocaine) b. Nifedipine (Procardia) and lidocaine c. Nitroglycerin (Nitro-Bid IV) and esmolol (Brevibloc) d. Nifedipine and nitroglycerin 30. Conditions necessary for the development of a positive sense of self-esteem include: a. Consistent limits b. Critical environment c. Inconsistent boundaries

d. Physical discipline

y Answer C. Twelve-step programs focus on recovery 1 day at a time. Such programs discourage people from claiming that they will never again use a substance, because relapse is common. The belief that one may use a limit amount of an abused substance indicates denial. Substituting one abused substance for another predisposes the patient to cross-addiction. y Answer B. By establishing a one-to-one relationship, the nurse helps the patient learn how to interact with other people in new situations. The other options are appropriate but should take place only after the nurse-patient relationship is established. y Answer D. A compulsion is a repetitive act or impulse helps a person to reduce anxiety unconsciously. An obsessive-compulsive patient does not want to call attention to self and cannot control thoughts. This patients priority is to reduce anxiety, not maintain the safety of the home. y Answer A. By acknowledging how the patient feels, this response encourages further expression of thoughts and feelings. Minimizing feelings or offering empty reassurances is not therapeutic or helpful. Deep breathing or preoperative medication would be appropriate only after the patients fears have been expressed and dealt with. y Answer C. The nurse must determine whether the restraints have been applied correctly to make sure that patients circulation and respiration are not restricted and that adequate padding has been used. The nurse should document the patients response and status carefully after the restraints are applied. All staff members involved in restraining patients should be aware of hospital policy before using restraints. If p.r.n. medication is ordered, it should be given before the restraints are in place and with the assistance of other team members. The nurse should attend to the patients elimination and hydration needs after the patient is properly restrained. y Answer D. Although most phenothiazine produce some effects within minutes to hours, their antipsychotic effects may take several weeks to appear. y Answer C. Most states allow restraints to be used if the patient presents a danger to self or others. This danger must be reevaluated every few hours. If the patient is still a danger, restraints can be used until the violent behavior abates. No standing orders for restraints are allowed, and restraints are permitted only until more humane methods, such as sedatives, become more effective. Violent patients who are intoxicated with drugs or alcohol present a problem because they rarely can be sedated until the drug or alcohol is metabolized. In such cases, restraints may be needed for a longer period, but the patient must be closely observed. Obtaining consent is not always possible, especially when the patients violent behavior results from a psychosis, such as paranoid schizophrenia. y Answer C. Conditions requiring cautious use of amitriptyline include pregnancy, lactation, suicidal tendencies, cardiovascular disease, and impaired hepatic function. Hiatal hernia, hypernatremia, and hypokalemia do not affect amitriptyline therapy. y Answer B. Providing an opportunity for the client to express concern about a new medication and to make a choice about taking it can help the client regain a sense of control over his life. The client has the right to refuse the medication. Instead of simply ordering the client to take it, as in option 1, the nurse should provide the information the client needs to make an informed decision. Attempting to make the client feel guilty, as in option 3, or threatening the client, as option 4, would increase anxiety.

y Answer A. Decreased libido, retrograde ejaculation, and gynecomastia are all hormonal effects that can occur with antipsychotic medications. Reassure the client that the effects can be reversed or that changing medication may be possible. Polydipsia, akinesia, and dysphasia arent hormonal effects. y Answer A. Anxiety is a normal reaction to the termination of the nurse-client relationship. The nurse should help the client explore his feelings about the end of the therapeutic relationship. While anger about the termination may be a healthy response, banging the table, shouting, and other forms of acting out arent appropriate behavior. Withdrawal isnt a healthy response to the termination of a relationship. By rationalizing the termination, the client avoids expressing his feelings and emotions. y Answer A. The client with schizophrenia is commonly socially isolated and withdrawn; therefore, having the client spend more time by himself wouldnt be a desirable outcome. Rather, a desirable outcome would specify that the client spend more time with other clients and staff on the unit. Delusions are false personal beliefs. Reducing or eliminating delusional thinking using talking therapy and antipsychotic medications would be a desirable outcome. Protecting the client and others from harm is a desirable client outcome achieved by close observation, removing any dangerous objects, and administering medications. Because the client with schizophrenia may have difficulty meeting his or her own self-care needs, fostering the ability to perform self-care independently is a desirable client outcome. y Answer A. Because a client who has attempted suicide could try again, the nurse should search the clients belongings and room to remove any items that could be used in another suicide attempt. Expressing trust that the client wont cause self-harm may increase guilt and pain if the client cant live up to that trust. The nurse should search the clients belonging because the need to maintain a safe environment supersedes the clients right to privacy. Although frequent checks by staff members are helpful, they arent enough because the client may attempt suicide between checks. y Answer C. Displacement is a defense mechanism in which the client transfers his feelings for one person toward another person who is less threatening. Rationalization is a defense mechanism in which the client makes excuses to justify unacceptable feeling or behaviors. Repression is characterized by an involuntary blocking of unpleasant experiences from ones consciousness. Suppression is the conscious blocking of unpleasant experiences form ones awareness. y Answer C. The nurse should prepare a client for ECT in a manner similar to that for general anesthesia. For example, the client should receive nothing by mouth for 8 hours before ECT to reduce the risk of vomiting and aspiration. Also, the nurse should have the client void before treatment to decrease the risk of involuntary voiding during the procedure, remove any full denture, glasses, or jewelry to prevent breakage or loss; and make sure the client is wearing a hospital gown or loose-fitting clothing to allow unrestricted movement. Usually, these preparations arent indicated for a client undergoing physical therapy, neurologic examination, or cardiac stress testing. y Answer D. A flexible care plan needed for any client who behaves in a suspicious, withdrawn, or regressed manner or who has thought disorder. Because such a client communicates at different levels and is in control of himself at various times, the nurse must be able to adjust nursing care as the situation warrants. The nurses role should be clear, however, the boundaries or limits of this role should be flexible enough to meet client needs. Because a client with schizophrenia fears closeness and affection, a warm approach may be too threatening.

Expressing empathy is important, but centering interventions on clear defined limits is impossible because the clients situation may change without warning. y Answer D. When caring for a client with OCD, the goal is to systematically decrease the undesirable behavior. (Therapy may not completely extinguish certain behaviors.) Expecting to omit one behavior each day is unrealistic because the client may have used ritualistic behavior would perpetuate the undesirable behavior. y Answer D. Fluphenazine decanoate is a long-acting antipsychotic agent given by injection. Because it has a 4-week duration of action, its commonly prescribed for outpatients with a history of medication noncompliance. Chlorpromazine, also an antipsychotic agent, must be administered daily to maintain adequate plasma levels, which necessitates compliance with the dosage schedule. Imipramine, a tricyclic antidepressant, and lithium carbonate, a mood stabilizer, are rarely used to treat clients with chronic schizophrenia. y Answer A. Individuals with dependent personality disorder typically shows indecisiveness, submissiveness, and clinging behavior so that others will make decisions for them. These clients feel helpless and uncomfortable when alone and dont show interest in solitary activities. They also pursue relationships in order to have someone to take care of them. Although clients with dependent personality disorder may become depressed and suicidal if their needs arent met, this isnt a typical response. y Answer C. Abstract thinking is the ability to conceptualize and interpret meaning. Its higher level of intellectual functioning than concrete thinking, in which the client explains the proverb by its literal meaning. Rational thinking involves the ability to think logically, make judgments, and be goal-directed. Tangential thinking is scattered, non-goal-directed, and hard to follow. Clients with such conditions as organic brain disease and schizophrenia typically cant conceptualize and comprehend abstract meaning. They interpret such statement as Dont cry over spilled milk in a literal sense, such as Even if you spill your milk, you shouldnt cry about it. y Answer D. Although all these options may apply to this client, safety is the nurses first priority in caring for any suicidal client. The nurse can address the clients hopelessness, ineffective coping, and spiritual distress later in therapy. y Answer A. Focusing on the clients blindness can positively reinforce the blindness and further promote the use of maladaptive behaviors to obtain secondary gains. The client should be encouraged to participate in his own care as much as possible to avoid fostering dependency. To promote self-esteem, give positive reinforcement for what the client can do. Blindness and other physical symptoms in a conversion disorder arent under the clients control and are real to him. Eye exercises wont resolve the clients blindness because no organic pathology is causing the symptoms. y Answer D. The aggressor is negative and hostile and uses sarcasm to degrade others. The role of the blocker is to resist group efforts. The monopolizer controls the group by dominating conversations. The recognition seeker talks about accomplishments to gain attention. y Answer C. Circulation as well as skin and nerve damage can occur within 15 minutes. Checking every hour, 2 hours, or 8 hours isnt often enough and could result in permanent damage to the clients extremities. Restraints should be removed every 2 hours, and range-ofmotion exercises should be performed. y Answer A. When the childs injuries are inconsistent with the history given or impossible because of the childs age and developmental stage, the emergency department nurse should be suspicious that child abuse is occurring. The parents may tell different stories because their

perception may be different regarding what happened. If they change their story when different health care workers ask the same question, this is a clue that child abuse may be a problem. Child abuse occurs in all socioeconomic groups. Parent may argue and be demanding because of the stress of having an injured child. y Answer C. Abuse and neglect lead to poor self-concept and confusion, the basis for unhealthy personal boundaries. Healthy boundaries are established in childhood when parent provide consistent, supportive limits and attention. y Answer D. This client requires a vasodilation such as nifedipine to treat hypertension, and a beta-adrenergic blocker such as esmolol to reduce the heart rate. Lidocaine, an antirrhythmic, isnt indicated because the client doesnt have an arrhythmia. Although nitrolycerin may be used to treat coronary vasospasm, it isnt the drug of choice in hypertension. y Answer A. A structured lifestyle demonstrates acceptance and caring provides a sense of security. A critical environment erodes a persons esteem. Inconsistent boundaries lead to feelings of insecurity and lack of concern. Physical discipline can decrease self-esteem. 1. Flumazenil (Romazicon) has been ordered for a male client who has overdosed on oxazepam (Serax). Before administering the medication, nurse Gina should be prepared for which common adverse effect? a. Seizures b. Shivering c. Anxiety d. Chest pain 2. Nurse Tim is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to: a. avoid shopping for large amounts of food b. control eating impulses c. identify anxiety-causing situations d. eat only three meals per day 3. A female client whos at high risk for suicide needs close supervision. To best ensure the clients safety, nurse Gio should: a. check the client frequently at irregular intervals throughout the night b. assure the client that the nurse will hold in confidence anything the client says c. repeatedly discuss previous suicide attempts with the client d. disregard decreased communication by the client because this is common in suicidal clients 4. Which of the following drugs should nurse Marlyn prepare to administer to a client with a toxic acetaminophen (Tylenol) level? a. deferoxamine mesylate (Desferal) b. succimer (Chemet) c. flumazenil (Romazicon) d. acetylcysteine (Mucomyst) 5. A male client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is nurse Apple most likely to administer to reduce the symptoms of

alcohol withdrawal? a. naloxone (Narcan) b. haloperidol (Haldol) c. magnesium sulfate d. chlordiazepoxide (Librium) 6. During postprandial monitoring, a female client with bulimia nervosa tells the nurse, You can sit with me, but youre just wasting your time. After you sat with me yesterday, I was still able to purge. Today, my goal is to do it twice. What is the nurses best response? a. I trust you not to purge. b. How are you purging and when do you do it? c. Dont worry. I wont allow you to purge today. d. I know its important for you to feel in control, but Ill monitor you for 90 minutes after you eat. 7. A male client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, It felt so wonderful to get high. Which of the following is the most appropriate response? a. If you continue to talk like that, Im going to stop speaking to you. b. You told me you got fired from your last job for missing too many days after taking drugs all night. c. Tell me more about how it felt to get high. d. Dont you know its illegal to use drugs? 8. For a female client with anorexia nervosa, nurse Jay is aware that which goal takes the highest priority? a. The client will establish adequate daily nutritional intake b. The client will make a contract with the nurse that sets a target weight c. The client will identify self-perceptions about body size as unrealistic d. The client will verbalize the possible physiological consequences of self-starvation 9. When interviewing the parents of an injured child, which of the following is the strongest indicator that child abuse may be a problem? a. The injury isnt consistent with the history or the childs age b. The mother and father tell different stories regarding what happened c. The family is poor d. The parents are argumentative and demanding with emergency department personnel 10. For a female client with anorexia nervosa, nurse Rose plans to include the parents in therapy sessions along with the client. What fact should the nurse remember to be typical of parents of clients with anorexia nervosa? a. They tend to overprotect their children b. They usually have a history of substance abuse c. They maintain emotional distance from their children d. They alternate between loving and rejecting their children

11. In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After the health care team repairs her lacerations, she waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the clients husband arrives, shouting that he wants to finish the job. What is the first priority of the health care worker who witnesses this scene? a. Remaining with the client and staying calm b. Calling a security guard and another staff member for assistance c. Telling the clients husband that he must leave at once d. Determining why the husband feels so angry 12. . Nurse Venus is caring for a client with bulimia. Strict management of dietary intake is necessary. Which intervention is also important? a. Fill out the clients menu and make sure she eats at least half of what is on her tray. b. Let the client eat her meals in private. Then engage her in social activities for at least 2 hours after each meal c. Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal d. Let the client eat food brought in by the family if she chooses, but she should keep a strict calorie count. 13. Nurse Mary is assigned to care for a suicidal client. Initially, which is the nurses highest care priority? a. Assessing the clients home environment and relationships outside the hospital b. Exploring the nurses own feelings about suicide c. Discussing the future with the client d. Referring the client to a clergyperson to discuss the moral implications of suicide 14. A 24-year old client with anorexia nervosa tells the nurse, When I look in the mirror, I hate what I see. I look so fat and ugly. Which strategy should the nurse use to deal with the clients distorted perceptions and feelings? a. Avoid discussing the clients perceptions and feelings b. Focus discussions on food and weight c. Avoid discussing unrealistic cultural standards regarding weight d. Provide objective data and feedback regarding the clients weight and attractiveness 15. Nurse Desmond is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products? a. Carbonated beverages b. Aftershave lotion c. Toothpaste d. Cheese 16. Nurse Faith is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan? a. Restrict visits with the family until the client begins to eat

b. Provide privacy during meals c. Set up a strict eating plan for the client d. Encourage the client to exercise, which will reduce her anxiety 17. Nurse Tina is aware that the victims of domestic violence should be assessed for what important information? a. Reasons they stay in the abusive relationship (for example, lack of financial autonomy and isolation) b. Readiness to leave the perpetrator and knowledge of resources c. Use of drugs or alcohol d. History of previous victimization 18. A male client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Police suspect the client was intoxicated at the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dl). The client later admits to drinking heavily for years. During hospitalization, the client periodically complains of tingling and numbness in the hands and feet. Nurse Gio realizes that these symptoms probably result from: a. acetate accumulation b. thiamine deficiency c. triglyceride buildup. d. a below-normal serum potassium level 19. A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect that the child was abused? a. The child cries uncontrollably throughout the examination b. The child pulls away from contact with the physician. c. The child doesnt cry when the shoulder is examined d. The child doesnt make eye contact with the nurse. 20. When planning care for a client who has ingested phencyclidine (PCP), nurse Wayne is aware that the following is the highest priority? a. Clients physical needs b. Clients safety needs c. Clients psychosocial needs d. Clients medical needs 21. The nurse is aware that the outcome criteria would be appropriate for a child diagnosed with oppositional defiant disorder? a. Accept responsibility for own behaviors b. Be able to verbalize own needs and assert rights. c. Set firm and consistent limits with the client d. Allow the child to establish his own limits and boundaries 22. A male client is found sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at her

bleeding wrists while staff members call for an ambulance. How should nurse Grace approach her initially? a. Enter the room quietly and move beside her to assess her injuries b. Call for staff back-up before entering the room and restraining her c. Move as much glass away from her as possible and sit next to her quietly d. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her 23. A female client with anorexia nervosa describes herself as a whale. However, the nurses assessment reveals that the client is 5 8 (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the clients unrealistic body image, which intervention should nurse Angel be included in the plan of care? a. Asking the client to compare her figure with magazine photographs of women her age b. Assigning the client to group therapy in which participants provide realistic feedback about her weight c. Confronting the client about her actual appearance during one-on-one sessions, scheduled during each shift d. Telling the client of the nurses concern for her health and desire to help her make decisions to keep her healthy 24. Eighteen hours after undergoing an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature, 101.6 F (38.7 C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is screaming for someone to kill the bugs in the bed. Nurse Melinda should suspect: a. a postoperative infection b. alcohol withdrawal c. acute sepsis. d. pneumonia. 25. Clonidine (Catapres) can be used to treat conditions other than hypertension. Nurse Sally is aware that the following conditions might the drug be administered? a. Phencyclidine (PCP) intoxication b. Alcohol withdrawal c. Opiate withdrawal . Answer A. Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Less common adverse effects include shivering, anxiety, and chest pain. 2. Answer C. Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for large amounts of food isnt a goal early in treatment. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the plan of care after initially addressing stress and underlying issues. Eating three meals per day isnt a realistic goal early in treatment.

3. Answer A. Checking the client frequently but at irregular intervals prevents the client from predicting when observation will take place and altering behavior in a misleading way at these times. Option B may encourage the client to try to manipulate the nurse or seek attention for having a secret suicide plan. Option C may reinforce suicidal ideas. Decreased communication is a sign of withdrawal that may indicate the client has decided to commit suicide; the nurse shouldnt disregard it (option D) 4. Answer D. The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion of toxic metabolites to nontoxic metabolites. Deferoxamine mesylate is the antidote for iron intoxication. Succimer is an antidote for lead poisoning. Flumazenil reverses the sedative effects of benzodiazepines. 5. Answer D. Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of alcohol withdrawal. Haloperidol (Haldol) may be given to treat clients with psychosis, severe agitation, or delirium. Naloxone (Narcan) is administered for narcotic overdose. Magnesium sulfate and other anticonvulsant medications are only administered to treat seizures if they occur during withdrawal. 6. Answer D. This response acknowledges that the client is testing limits and that the nurse is setting them by performing postprandial monitoring to prevent self-induced emesis. Clients with bulimia nervosa need to feel in control of the diet because they feel they lack control over all other aspects of their lives. Because their therapeutic relationships with caregivers are less important than their need to purge, they dont fear betraying the nurses trust by engaging in the activity. They commonly plot purging and rarely share their secrets about it. An authoritarian or challenging response may trigger a power struggle between the nurse and client. 7. Answer B. Confronting the client with the consequences of substance abuse helps to break through denial. Making threats (option A) isnt an effective way to promote self-disclosure or establish a rapport with the client. Although the nurse should encourage the client to discuss feelings, the discussion should focus on how the client felt before, not during, an episode of substance abuse (option C). Encouraging elaboration about his experience while getting high may reinforce the abusive behavior. The client undoubtedly is aware that drug use is illegal; a reminder to this effect (option D) is unlikely to alter behavior. 8. Answer A. According to Maslows hierarchy of needs, all humans need to meet basic physiological needs first. Because a client with anorexia nervosa eats little or nothing, the nurse must first plan to help the client meet this basic, immediate physiological need. The nurse may give lesser priority to goals that address long-term plans (as in option B), self-perception (as in option C), and potential complications (as in option D). 9. Answer A. When the childs injuries are inconsistent with the history given or impossible because of the childs age and developmental stage, the emergency department nurse should be suspicious that child abuse is occurring. The parents may tell different stories because their perception may be different regarding what happened. If they change their story when different health care workers ask the same question, this is a clue that child abuse may be a problem. Child abuse occurs in all socioeconomic groups. Parents may argue and be demanding because of the stress of having an injured child. 10. Answer A. Clients with anorexia nervosa typically come from a family with parents who are controlling and overprotective. These clients use eating to gain control of an aspect of their lives. The characteristics described in options B, C, and D isnt typical of parents of children with anorexia. 11. Answer B. The health care worker who witnesses this scene must take precautions to

ensure personal as well as client safety, but shouldnt attempt to manage a physically aggressive person alone. Therefore, the first priority is to call a security guard and another staff member. After doing this, the health care worker should inform the husband what is expected, speaking in concise statements and maintaining a firm but calm demeanor. This approach makes it clear that the health care worker is in control and may diffuse the situation until the security guard arrives. Telling the husband to leave would probably be ineffective because of his agitated and irrational state. Exploring his anger doesnt take precedence over safeguarding the client and staff. 12. Answer C. Allowing the client to select her own food from the menu will help her feel some sense of control. She must then eat 100% of what she selected. Remaining with the client for at least 1 hour after eating will prevent purging. Bulimic clients should only be allowed to eat food provided by the dietary department. 13. Answer B. The nurses values, beliefs, and attitudes toward self-destructive behavior influence responses to a suicidal client; such responses set the overall mood for the nurse-client relationship. Therefore, the nurse initially must explore personal feelings about suicide to avoid conveying negative feelings to the client. Assessment of the clients home environment and relationships may reveal the need for family therapy; however, conducting such an assessment isnt a nursing priority. Discussing the future and providing anticipatory guidance can help the client prepare for future stress, but this isnt a priority. Referring the client to a clergyperson may increase the clients trust or alleviate guilt; however, it isnt the highest priority. 14. Answer D. By focusing on reality, this strategy may help the client develop a more realistic body image and gain self-esteem. Option A is inappropriate because discussing the clients perceptions and feeling wouldnt help her to identify, accept, and work through them. Focusing discussions on food and weight would give the client attention for not eating, making option B incorrect. Option C is inappropriate because recognizing unrealistic cultural standards wouldnt help the client establish more realistic weight goals. 15. Answer B. Disulfiram may be given to clients with chronic alcohol abuse who wish to curb impulse drinking. Disulfiram works by blocking the oxidation of alcohol, inhibiting the conversion of acetaldehyde to acetate. As acetaldehyde builds up in the blood, the client experiences noxious and uncomfortable symptoms. Even alcohol rubbed onto the skin can produce a reaction. The client receiving disulfiram must be taught to read ingredient labels carefully to avoid products containing alcohol such as aftershave lotions. Carbonated beverages, toothpaste, and cheese dont contain alcohol and dont need to be avoided by the client. 16. Answer C. Establishing a consistent eating plan and monitoring the clients weight are important for this disorder. The family should be included in the clients care. The client should be monitored during meals not given privacy. Exercise must be limited and supervised. 17. Answer B. Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them. Nurses can then provide the victims with information and options to enable them to leave when they are ready. The reasons they stay in the relationship are complex and can be explored at a later time. The use of drugs or alcohol is irrelevant. There is no evidence to suggest that previous victimization results in a persons seeking or causing abusive relationships. 18. Answer B. Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake. Treatment includes reducing alcohol intake, correcting nutritional deficiencies through diet and vitamin supplements, and preventing such residual disabilities as foot and wrist drop. Acetate accumulation, triglyceride buildup, and a below-

normal serum potassium level are unrelated to the clients symptoms. 19. Answer C. A characteristic behavior of abused children is lack of crying when they undergo a painful procedure or are examined by a health care professional. Therefore, the nurse should suspect child abuse. Crying throughout the examination, pulling away from the physician, and not making eye contact with the nurse are normal behaviors for preschoolers. 20. Answer B. The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as the staff. Drug effects are unpredictable and prolonged, and the client may lose control easily. After safety needs have been met, the clients physical, psychosocial, and medical needs can be met. 21. Answer A. Children with oppositional defiant disorder frequently violate the rights of others. They are defiant, disobedient, and blame others for their actions. Accountability for their actions would demonstrate progress for the oppositional child. Options C and D arent outcome criteria but interventions. Option B is incorrect as the oppositional child usually focuses on his own needs. 22. Answer D. Ensuring the safety of the client and the nurse is the priority at this time. Therefore, the nurse should approach the client cautiously while calling her name and talking to her in a calm, confident manner. The nurse should keep in mind that the client shouldnt be startled or overwhelmed. After explaining that the nurse is there to help, the nurse should observe the clients response carefully. If the client shows signs of agitation or confusion or poses a threat, the nurse should retreat and request assistance. The nurse shouldnt attempt to sit next to the client or examine injuries without first announcing the nurses presence and assessing the dangers of the situation. 23. Answer D. A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. Therefore, the client needs assistance with making decisions about health. Instead of protecting the clients health, options A, B, and C may serve to make the client defensive and more entrenched in her unrealistic body image. 24. Answer B. The clients vital signs and hallucinations suggest delirium tremens or alcohol withdrawal syndrome. Although infection, acute sepsis, and pneumonia may arise as postoperative complications, they wouldnt cause this clients signs and symptoms and typically would occur later in the postoperative course 25. Answer C. Clonidine is used as adjunctive therapy in opiate withdrawal. Benzodiazepines, such as chlordiazepoxide (Librium), and neuropleptic agents, such as haloperidol, are used to treat alcohol withdrawal. Benzodiazepines and neuropleptic agents are typically used to treat PCP intoxication. Antidepressants and medications with dopaminergic activity in the brain, such as fluoxotine (Prozac), are used to treat cocaine withdrawal.