Evolve psychiatric exam

1.
A schizophrenic client says, “I’m away for the day ... but don’t think we should play … or do
we have feet of clay?” Which alteration in the client’s speech does the nurse document?
A) Neologism
B) Word salad
C) Clang association
D) Associative looseness

Feedback: INCORRECT
Rationale: Clang association is the meaningless rhyming of words in which the rhyming is
more important than the context of the words. A neologism is a made-up word that has
meaning only to the client. Word salad is the term for a mixture of meaningless phrases,
either to the client or to the listener. Associative looseness is a term used to describe
schizophrenic speech in which connections and threads are interrupted or missing.

Test-Taking Strategy: Knowledge of the speech patterns exhibited by the client with
schizophrenia is needed to answer this question. Focus on the data in the question and note
the meaningless rhyming of words. Review these speech patterns if you had difficulty with
this question.

Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:
A communication approach to evidence-based care (p. 281). St. Louis: Saunders.

Cognitive Ability: Applying

Client Needs: Psychosocial Integrity

Integrated Process: Communication and Documentation

Content Area: Mental Health

Points Earned: 0.0/1.0

2.
A client with schizophrenia and his parents are meeting with the nurse. One of the young
man’s parents says to the nurse, “We were stunned when we learned that our son had
schizophrenia. He was no different than from his older brother when they were growing up.
Now he’s had another relapse, and we can’t understand why he stopped his medication.”
Which response by the nurse is appropriate?
A) Telling the parents, “Medication noncompliance is the most frequent reason that people
with this diagnosis relapse.”
B) Telling the parents, “Well, it’s his decision to take his medicine, but it’s yours to have him
live with you if he stops the medication.”
C) Asking the client, “How can we help you to take your medicine or to tell us when you’re
having problems so that your medication can be adjusted?”

D) Saying to the parents, “Your concerns are appropriate, but I wonder whether your son
was having trouble telling someone that he had concerns about his medication.”

Feedback: INCORRECT
Rationale: The therapeutic response is the one in which the nurse models speaking directly
to the client. This facilitates further assessment of the situation and helps elicit the causes
of and motivations for the client’s behavior for both the nurse and the family. In the correct
option, the nurse also seeks clarification of the degree of openness and mutuality felt by the
client and his family toward each other. The nurse provides information to the family when
stating that noncompliance is the most frequent reason for relapse in people with this
diagnosis. However, the statement is nontherapeutic at this time because it does not
facilitate the expression of feelings. The nurse uses a superego style of communication
when stating, “Well, it’s his decision to take his medicine, but it’s yours to have him live with
you if he stops the medication.” The content of this statement may be true, but it is
nontherapeutic in that it carries a threatening message and may prevent the family from
trusting the nurse. By stating, “Your concerns are appropriate, but I wonder whether your
son was having trouble telling someone that he had concerns about his medication,” the
nurse gives approval and prematurely analyzes the client’s motivation without sufficient
assessment.

Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and
remember to focus on the client’s feelings. Also note that the correct option is the only
option in which the nurse directly addresses the client. Review therapeutic communication
techniques if you had difficulty with this question.

Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31).
St. Louis: Mosby.
Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: A
communication approach to evidence-based care (p. 297). St. Louis: Saunders.






3.
An acutely ill schizophrenic client says to the nurse, “He keeps saying that he likes you, and
I keep telling him you’re married, but he won’t listen, and I think he’s going to get fresh
with you.” Once the nurse has determined that the client is hallucinating, which response to
the client would be most appropriate statement?
A) “Try not to listen to the voices right now so that I can talk with you.”
B) “I think that you can help him stop his behavior if you concentrate.”
C) “Tell him I said to mind his p’s and q’s or I’ll call the police on him.”

D) “I think that you’re trying to share your own feelings toward me, but you’re shy.”

Feedback: INCORRECT
Rationale: The appropriate statement by the nurse is the one that does not acknowledge the
client’s hallucinations. By responding, “I think that you can help him stop his behavior if you
concentrate” or “Tell him I said to mind his p’s and q’s or I’ll call the police on him,” the
nurse acknowledges the hallucinations. The nurse attempts to interpret the client’s thinking
with a statement such as “I think that you’re trying to share your own feelings toward me,
but you’re shy.”

Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and
remember that the nurse should not acknowledge the client’s hallucinations. Also note that
the correct option is the only one that encourages realistic verbalization from the client.
Review therapeutic communication techniques with a client who is hallucinating if you had
difficulty with this question.

References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-
31). St. Louis: Mosby.
communication approach to evidence-based care (pp. 287, 288). St. Louis: Saunders.






4.
A client says to the nurse, “It’s over for me — the whole thing is over.” Which response by
the nurse would be therapeutic?
A) “What do you mean, ‘The whole thing is over’?”
B) “Over? Well, that sounds pretty drastic to me. Let’s discuss this in the strictest
confidence.”
C) “Can you tell me more about why it’s over for you? I’ll keep your thoughts strictly
confidential.”
D) “Let’s talk more about your feeling that the whole thing is over for you. This is important,
and I may need to share your feelings with other staff members.”

Feedback: INCORRECT
Rationale: The therapeutic response seeks clarification, employs paraphrasing, and informs
the client that the nurse needs to share any information that requires crisis intervention
with other staff members. Asking, “What do you mean, ‘The whole thing is over’?” employs
paraphrasing, but the message is blunt and closed-ended. In stating, “Over? Well, that
sounds pretty drastic to me. Let’s discuss this in the strictest confidence,” the nurse uses

hysterical exaggeration (at an inappropriate time) and gives incorrect information regarding
confidentiality. In stating, “Can you tell me more about why it’s over for you? I’ll keep your
thoughts strictly confidential,” the nurse uses the therapeutic technique of seeking
clarification but does not clarify with the client that the information might need to be
shared.

Test-Taking Strategy: Use the process of elimination. Eliminate the options that are
comparable or alike and indicate that shared information will be maintained as confidential.
To select from the remaining options, focus on the statement that addresses the client’s
feelings. Review therapeutic communication techniques if you had difficulty with this
question.

St. Louis: Mosby.


Client Needs: Safe and Effective Care Environment




5.
A nurse performing a lethality assessment asks the client whether he is thinking of suicide.
Which statement by the client would be of most concern to the nurse?
A) “No, I wasn’t, but I am now, thanks to you.”
B) “I hadn’t thought of that, but I can see that you are.”
C) “Of course not, but there are days when I think that I should be.”
D) “What is suicide going to do for me except get me excommunicated from the church?”

Feedback: CORRECT
Rationale: The client’s response that he is now thinking about suicide is of the greatest
concern to the nurse. In making the statement “I hadn’t thought of that, but I can see that
you are” the client projects his own thoughts of suicide onto the nurse. In stating, “Of
course not, but there are days when I think that I should be,” the client is being sarcastic
but is not specifically talking about suicide. In stating, “What is suicide going to do for me
except get me excommunicated from the church?” the client indicates that suicide is not an
option because of his religious beliefs.

Test-Taking Strategy: Use the process of elimination and note the strategic words “of most
concern to the nurse.” Note the words “but I am now” in the correct option. This is the only
option that identifies definite suicidal thoughts. Review lethality assessment in the suicidal
client if you had difficulty with this question.


Cognitive Ability: Analyzing


Integrated Process: Nursing Process/Assessment



6.
A client who has expressed suicidal ideation in the past says to the nurse, while shuffling
several documents in an effort to organize them, “Well, I’m feeling so much better now
since I got organized. My lawyer wrote my will and durable power of attorney.” Which
response by the nurse is appropriate?
A) “Good grief! You don’t look organized to me.”
B) “Okay, what are you up to today? Your behavior is not appropriate.”
C) “You talk about getting organized. Are you thinking of killing yourself?”
D) “If you keep behaving like this, you know that I’ll have to tell the doctor, and we’ll have
to seclude you.”

Feedback: CORRECT
Rationale: The client is exhibiting behaviors that indicate plans for suicide. Talking of
suddenly “feeling so much better” and putting affairs in order are key verbal and behavioral
clues that the client is planning to commit suicide. In exclaiming, “Good grief! You don’t look
organized to me,” the nurse nontherapeutically uses hysterical exaggeration, which
minimizes the client’s feelings. In asking, “Okay, what are you up to today? Your behavior is
not appropriate,” the nurse uses teasing to determine the client’s behaviors, which
minimizes them. Additionally, the nurse is employing a nontherapeutic technique of judging.
In stating, “If you keep behaving like this, you know that I’ll have to tell the doctor and we’ll
have to seclude you,” the nurse uses a threat.

Test-Taking Strategy: Use the process of elimination. Focus on the information in the
question and note the relationship between the words “expressed suicidal ideation” in the
question and “thinking of killing yourself” in the correct option. Review the clues that
indicate the potential for suicide if you had difficulty with this question.

Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31,






7.
An adolescent client says, “I’m just a burden to my folks. They wish I’d never been born. My
dad told me he had to marry Mom because she got pregnant.” Which response by the nurse
would be therapeutic?
A) “You’re feeling that your folks didn’t want you, but they chose to marry and have you.”
B) “You feel that you were a burden and not wanted? Let’s talk with your parents to see
whether you’re right.”
C) “Let’s speak with your parents about what you’ve just told me. Let’s ask whether you
were truly unwanted.”
D) “Sounds like your father was very inappropriate, but I’m certain that he didn’t mean that
you were a burden to him.”

Feedback: INCORRECT
Rationale: In the correct option, the nurse uses reflection to explore the client’s lethality risk
and then uses reframing to determine whether the client is able to view what happened in a
different way. In suggesting, “You feel that you were a burden and not wanted? Let’s talk
with your parents to see whether you’re right,” the nurse uses paraphrasing but is then
nontherapeutic in trying to persuade the client to talk to the parents. In suggesting, “Let’s
speak with your parents about what you’ve just told me. Let’s ask whether you were truly
unwanted,” the nurse uses a parental approach, which may be threatening to the client, who
seems to have been unable to talk with the parents before now. In stating, “Sounds like
your father was very inappropriate, but I’m certain that he didn’t mean that you were a
burden to him,” the nurse offers an opinion about the client’s father and then provides false
reassurance.

comparable or alike and address discussing the client’s feelings with the parents. In
selecting from the remaining options, remember to focus on the client’s feelings. This will
direct you to the correct option. Review therapeutic communication techniques if you had







8.
A client says to the nurse, “I’ve ruined my life. I left college with only a few credits to go. I
keep telling myself that I’m going to make it as a writer, but I’ll be a loser and a nothing for
the rest of my life.” Which response by the nurse is therapeutic?
A) “What are you saying? Sounds like you need to pull yourself together and go back to
school.”
B) “Having faith in yourself is one thing, but looking at your alternatives realistically is
another.”
C) “You seem to be saying that your choices are final and that you’ve lost any other
opportunities.”
D) “Sounds like you feel that things should come easy for you, unlike the rest of us, who
work for what we get.”

Feedback: INCORRECT
Rationale: The client in this question is engaging in catastrophizing rather than reframing
and viewing other alternatives. The task for the nurse is to assess the lethality of the client’s
situation and to help the client feel empowered to take another course of action and find the
perseverance and confidence to do so. The therapeutic response here is the one that is
nonjudgmental. In responding, “What are you saying? Sounds like you need to pull yourself
together and go back to school,” or “Sounds like you feel that things should come easy for
you, unlike the rest of us, who work for what we get,” the nurse communicates with the
client as a parent, using a judging style. In stating, “Having faith in yourself is one thing,
but looking at your options realistically is another,” the nurse communicates prematurely
and gives advice.

Test-Taking Strategy: Use the process of elimination and your knowledge of therapeutic
communication techniques. Eliminate the options that are comparable or alike in that the
nurse uses a judging style to deal with the client. To select from the remaining options,
eliminate the option that is nontherapeutic in that the nurse gives advice. Review
therapeutic communication techniques if you had difficulty with this question.







9.
A client who has twice attempted suicide says, “If people would just leave me alone and let
me do what I want with my life, I could get on with what I want to do.” Which response
should the nurse should give to the client?
A) “Of course you can’t be left alone to get on with what you want to do.”
B) “Okay, go ahead and do whatever you want to do. Human beings have free will.”
C) “You’ve tried to end your life twice, yet you feel that everyone should let you do what you
want to do?”
D) “Sounds like you’re angry with people for caring enough about you to try to keep you
from hurting yourself.”

Feedback: CORRECT
Rationale: The therapeutic response is the one that offers reflection, which permits the client
to observe the content of what she is saying. In stating, “Of course, you can’t be left alone
to get on with what you want to do,” the nurse makes a response that is social and belittles
the client’s feelings. In stating, “Okay, go ahead and do whatever you want to do. Human
beings have free will,” the nurse makes a response that seems sarcastic and angry; it is also
judgmental and biased. In stating, “Sounds like you’re angry with people for caring enough
about you to try to keep you from hurting yourself,” the nurse makes a premature
judgment.

Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. The
correct option is the only response that is therapeutic in that it uses reflection. Review

communication approach to evidence-based care (pp. 413, 415, 416). St. Louis: Saunders.






10.
A homeless client with an antisocial disorder is brought to the emergency department by the
police after disturbing customers in a department store. The client says to the nurse, “I
need to be hospitalized. It’s getting cold out, and I need a warm bed. If you don’t get me
into a hospital, I’ll jump off a bridge.” Which nursing intervention would be therapeutic?

A) Sending the client to the psychiatric hospital intake center immediately for evaluation
B) Asking the police to pick the client up and arrest him for vagrancy, as they should have
done immediately
C) Discharging the client with a follow-up appointment for the next day and guaranteeing
him a hospital bed if he shows up
D) Sending the client to a shelter that will provide temporary housing if he signs a contract
agreeing not to attempt suicide

Feedback: CORRECT
Rationale: The client is clearly using suicide as a threat so that he will be hospitalized. As
long as self-harm is not an issue, providing the client with shelter will meet his needs.
Sending the client to the psychiatric hospital intake center immediately for evaluation is an
intervention that should be used if the client refuses to sign a contract for “no suicide.”
Guaranteeing the client a hospital bed if he shows up for a follow-up appointment is
manipulation, which is a nontherapeutic intervention. The nurse would not order the police
to arrest a client.

Test-Taking Strategy: Use the process of elimination. Eliminate the option that indicates
arresting the client, because it is not the nurse’s role to determine who requires arrest by
the police. Next eliminate the option that involves manipulation. From the remaining
options, select the option that provides the client shelter and addresses the risk of self-
harm. Review self-harm issues and the appropriate nursing interventions if you had difficulty
with this question.

References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., p. 633).
St. Louis: Mosby.



Integrated Process: Nursing Process/Implementation



11.
A client is admitted to the medical-surgical unit of a hospital, and suicide precautions are
taken until the client can be admitted to the psychiatric unit. Which nursing intervention
does the nurse implement?
A) Placing the client in a private room and locking the client’s closets and bathroom
B) Placing the client in a private room and removing all knives and glass from the client’s
meal tray
C) Allowing the client to go out on pass as long as the client is accompanied by a
responsible adult

D) Placing the client in a semiprivate room, providing plastic utensils for eating, and keeping
an arm’s distance from the client at all times

Feedback: INCORRECT
Rationale: When a client is suicidal, someone must be at arm’s length at all times, observing
the client, and the client must be in view at all times, even while toileting and showering.
Plastic utensils are used for eating. A semiprivate room is better than isolation in a private
room. Searching the client and the client’s room for harmful objects is done openly and
randomly. Glass mirrors are removed and the bathroom is harmproofed by replacing the
metal shower curtain rod with a plastic rod that falls when 50 pounds of pressure is placed
on it. Off-unit passes are not issued when a client is suicidal.

Test-Taking Strategy: Use the process of elimination and focus on the subject, suicide
precautions. Eliminate the options that are comparable or alike and involve the provision of
a private room, because this environment further isolates the client. Next recall that a
suicidal client would not be allowed off the nursing unit. Review suicide precautions if you
had difficulty with this question.

St. Louis: Mosby.






12.
A client is admitted to the psychiatric inpatient unit and suicide precautions are instituted.
Which of the following interventions does the nurse implement?
A) Restricting visitors
B) Placing the client in a private room and locking the bathroom door
C) Removing perfume, shampoo, and other toiletries from the client’s room
D) Placing flowers brought to the client in a small glass vase and putting them in the client’s
room

Feedback: CORRECT
Rationale: When suicide precautions are instituted, all of the client’s belongings that are
potentially harmful are removed and placed in a locked area from which the nursing staff
can retrieve them as the client needs to use them. Visitors are not restricted. However, any
items that a visitor brings to the client must be checked by the nurse. Glass items are not
placed in the suicidal client’s room.

Test-Taking Strategy: Use the process of elimination and focus on the subject, suicide
precautions. Eliminate the option that is a violation of client rights; the client is allowed to
have visitors. Next eliminate the options that contain the words “private room” and “glass.”
Review suicide precautions if you had difficulty with this question.

Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 326,






13.
A client who is undergoing psychiatric counseling calls a nurse on a hotline, crying, and
states, “My priest assaulted me when I was an altar boy, and my dad just found out. He’s
got a gun, and he’s driving over to the church rectory. I don’t know what to do.” Which
response by the nurse is most appropriate initially?
A) “How did your dad learn of your abuse by clergy?”
B) “Call the police immediately and then call the priest to warn him that your dad has a
gun.”
C) “Call the priest immediately and tell him to lock the doors until the police arrive. I’ll call
the police.”
D) “You will want to come in to see our psychiatrist with your father, but, for now, call the
police and tell them what happened.”

Feedback: INCORRECT
Rationale: Usually the volunteers on hotlines are trained to keep the client on the line, but in
this case, the duty to warn the priest of the danger he is facing is paramount. When
violence erupts, the nurse must think and act quickly and with clarity. “How did your dad
learn of your abuse by clergy?” is off focus and inappropriate to the situation. Telling the
client, “Call the police immediately and then call the priest to warn him that your dad has a
gun,” is incorrect, because the priest should be warned first. In stating, “You will want to
come in to see our psychiatrist with your father, but, for now, call the police and tell them
what happened,” the nurse does not focus on the imminent violence described in the
question.

Test-Taking Strategy: Note the strategic words “initially.” Eliminate the options that are
comparable or alike and direct the client to call the police first. To select from the remaining
options, consider the seriousness of the situation. This will direct you to the correct option.
The priest needs to be warned of the danger. Review nursing responsibilities in violent
situations if you had difficulty with this question.

Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 130,






14.
A nurse determines that a client whose son died in a car accident is at risk for self-harm.
Which intervention is most appropriate initially?
A) Making a “no suicide” contract with the client
B) Telling the client that anger should be suppressed
C) Providing a peaceful place for the client to meditate
D) Helping the client control expression of his feelings

Feedback: CORRECT
Rationale: The nurse would first plan to implement a “no suicide” contract when a client is at
risk for self-harm. The safety of the client is the priority. The nurse would encourage the
client to express angry, hostile feelings, not suppress them. Providing a peaceful place for
the client to meditate is incorrect because the nurse would not want the client to isolate
himself. Rather, the nurse would promote social interaction for the client. The nurse would
help the client express (not control expression of) feelings that are painful.

Test-Taking Strategy: Use the process of elimination and note the strategic word “initially.”
Note the relationship between the words “at risk for self-harm” in the question and “‘no
suicide’ contract” in the correct option. Review initial interventions for the client at risk for
suicide if you had difficulty with this question.

Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., p. 327). St.
Louis: Mosby.






15.
A client says to the nurse, “I’m worried about my husband. He’s talking about ending it all
since his law practice dropped off and his son by his late first wife died of a drug overdose —
but he’s too intelligent to hurt himself, isn’t he?” Which response by the nurse is
appropriate?
A) “Yes, he’s too intelligent to end it all.”
B) “I’m not sure. I don’t know him that well.”
C) “Most people who talk about ending it all are just looking for attention.”
D) “Your husband is displaying behaviors that indicate a risk for self-harm.”

Feedback: CORRECT
Rationale: Risk factors for suicide include male gender, professional status (physician,
attorney, dentist, military personnel), loss to death, financial problems, and physical illness.
Other risk indicators include a suicide plan, depressed mood, and prior attempts at suicide.
In stating, “Yes, he’s too intelligent to end it all,” the nurse provides false reassurance. In
responding, “I’m not sure. I don’t know him that well,” the nurse may be accurate, but the
answer avoids the client’s concern. The statement “Most people who talk about ending it all
are just looking for attention.” is inaccurate. Any implication of suicide should be taken
seriously.

Test-Taking Strategy: Use the process of elimination and focus on the data in the question.
Recalling the risk factors associated with suicide will direct you to the correct option. Review
these risk factors if you had difficulty with this question.

Louis: Mosby.






16.
A client says to the nurse, “I came in to see you because I’ve been off my medication for 4
years but I feel as though I may be getting depressed again. I’ve been despondent again
and thinking I should have ended it. That’s why I’m here to get help.” Which response by
the nurse would be therapeutic?

A) “Well, you really have had a good long drug-free time, but it sounds as if the doctor
needs to reorder your medication at once.”
B) “If you’ve been able to be drug free all this time, you probably don’t need to restart the
medicine. You probably just need some therapy to help you manage stress.”
C) “Well, it’s been more than 4 years, so you’ve done really well. Sounds like you’re right
about getting depressed again, though. Can you tell me what’s been happening with you
lately?”
D) “Well, it’s similar to when a client is battered — things have to boil over before the police
can act — so you need to be suicidal to get admitted to a hospital or hurt yourself before
the doctor can restart the medication.”

Feedback: CORRECT
Rationale: The therapeutic response is the one in which the nurse validates the client’s drug-
free time. In addition, in the correct option the nurse validates the client’s self-assessment
and supports and offers positive reinforcement. Finally the nurse begins to assess the client
completely and attempts to identify precipitants. By stating, “Well, you really have had a
good long drug-free time, but it sounds as if the doctor needs to reorder your medication at
once,” the nurse is premature in determining that the medication needs to be restarted; a
thorough assessment must be performed first. In stating, “If you’ve been able to be drug
free all this time, you probably don’t need to restart the medicine. You probably just need
some therapy to help you manage stress,” the nurse jumps to giving advice and offering
suggestions without performing a complete assessment. In stating, “Well, it’s similar to
when a client gets battered — things have to boil over before the police can act — so you
need to be suicidal to get admitted to a hospital or hurt yourself before the doctor can
restart the medication,” the nurse provides an incorrect statement and sarcastic
information.

Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and the
steps of the nursing process, remembering that assessment is the first step. The only option
that involves the process of assessment is the correct option. Review therapeutic
communication techniques if you had difficulty with this question.

References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31,
286-287). St. Louis: Mosby.






17.

A client who delivered a baby 4 months ago says, “I keep thinking that this boy is some sort
of demon. All he does is cry. It’s as if I can’t feed him enough or satisfy him in any way. My
daughter never gave me this kind of trouble. I really can’t stand it.” Which statement by the
nurse is most important?
A) “Have you been having any thoughts of hurting your baby?”
B) “Do you think that something physically wrong is causing your baby to cry?”
C) “Do you think that your baby cries so frequently because he’s not getting enough
nourishment from breastfeeding?”
D) “You say that he doesn’t seem to be satisfied. Do you feel that this is significantly
different from when your daughter was a baby?”

Feedback: CORRECT
Rationale: The most important statement is the one in which the nurse assesses the client
for her risk of harming the baby. This client may be experiencing postpartum depression,
and the rumination over the baby could lead the mother to harm the baby. The statements
in the incorrect options change the subject and close off expressions of concern by the
client.

Test-Taking Strategy: Use the process of elimination. Noting the words “I really can’t stand
it” in the question will direct you to the correct option. Review assessment of the client at
risk for harming others if you had difficulty with this question.

References: Fortinash, K. & Holoday-Worret, P. (2008). Psychiatric mental health nursing (4th
ed., p. 225). St. Louis: Mosby.
Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., p. 286). St. Louis:
Mosby.






18.
An alcoholic client who has been admitted to the mental health unit states to the nurse,
“The judge made me come in here. My blood alcohol level was only 0.20% when the cop
pulled me over in my car.” Which statement by the nurse is most appropriate?
A) “Did you ask the judge to clarify his decision to make you come here?”
B) “This limit means that you had consumed enough alcohol to put you close to the legal
intoxication level. You were lucky because you just missed that level.”
C) “Well, the legal limit is much less than that, so you avoided a drunken driving charge by
coming here. Seems to me that the judge treated you pretty leniently by allowing you to
take refuge here. Don’t you agree?”

D) “This level means that you consumed several drinks of alcohol and would be experiencing
depressed motor function of the brain. You would have been staggering and clumsy and
your judgment would have been impaired, but you seem to feel that the judge was
unreasonable for sending you here.”

Feedback: INCORRECT
Rationale: In most states (although the blood alcohol level, or BAL—designated as the
indicator of intoxication—does vary), the legal alcohol limit is 0.08%. The most appropriate
response is the one that teaches the client about his blood alcohol level and directs him to
focus on his action and behaviors. In asking, “Did you ask the judge to clarify his decision to
make you come here?” the nurse seeks clarification from the client, which closes off the
expression of feelings by changing the focus of the discussion. In stating, “This reading
means that you had consumed enough alcohol to put you close to the legal intoxication
level. You were lucky because you just missed that level,” the nurse gives inaccurate
information about the BAL. In responding, “Well, the legal limit is much less than that, so
you avoided a drunken driving charge by coming here. Seems to me that the judge treated
you pretty leniently by allowing you to take refuge here. Don’t you agree?” the nurse gives
opinions and is judgmental, then asks for agreement in a sarcastic style of communication.

Test-Taking Strategy: Use the process of elimination and your knowledge of BAL. Recalling
that in most states the legal alcohol limit is 0.08% will direct you to the correct option.
Review the BAL if you had difficulty with this question.

Louis: Mosby.


Client Needs: Physiological Integrity




19.
An adolescent client has graduated high school and is preparing to leave home to attend
college. The adolescent is distressed about this life change. The nurse plans to implement
crisis interventions, knowing that this situation is characteristic of:
A) A situational crisis
B) An individual crisis
C) A maturational crisis
D) An adventitious crisis

Feedback: CORRECT

Rationale: A maturational crisis involves the normal life transitions that produce changes in
individuals and how they perceive themselves, their roles, and their status. A situational
crisis occurs when a specific external event disturbs an individual's psychological
equilibrium. An adventitious crisis is an unpredictable tragedy that occurs without warning.
An individual may experience crisis; however, there is no formal type of crisis known as
"individual crisis."

Test-Taking Strategy: Use the process of elimination and your knowledge of the various types
of crises. Focus on the data in the question to direct you to the correct option. Review the
description of the types of crises if you had difficulty with this question.

A communication approach to evidence-based care (pp. 366, 367). St. Louis: Saunders.



Integrated Process: Nursing Process/Planning



20.
A heroin addict who overdoses on the drug is brought into the emergency department. The
client is having seizures, and the nurse notes that his pupils are dilated. Which of the
following interventions does the nurse anticipate that the emergency department physician
will prescribe?
A) Gastric lavage
B) Intravenous fluid
C) Naloxone (Narcan)
D) Ammonium chloride

Feedback: CORRECT
Rationale: An opioid antagonist such as naloxone would be prescribed to treat a heroin
overdose to reverse central nervous system depression. Gastric lavage is used for oral
overdose of or oral poisoning with certain substances. Intravenous fluid is a general
intervention in many situations. Ammonium chloride is used to acidify the urine of a client
who overdoses on amphetamines.

Test-Taking Strategy: Focus on the subject, an overdose of heroin. Recalling that naloxone is
an opioid antagonist will direct you to the correct option. Review this medication and the
treatment for heroin overdose if you had difficulty with this question.

References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-
centered collaborative care (6th ed., p. 1057). St. Louis: Saunders.







21.
A client in a retirement center rings the night alarm and says to the nurse, “Look at this old
man! He keeps breaking into my apartment! You’ve got to get him to stay out of here so I
can sleep.” Which statement by the nurse would be most therapeutic?
A) “Why not just throw him out yourself and lock up once and for all?”
B) “Now, you know that you’re always seeing things and people at night who aren’t there.”
C) “This must be very troubling to you, but I can’t see the old man. Perhaps I could stay
with you for an hour or so while you try to rest.”
D) “I’m sure you’re very frightened right now. Do you recall my telling you that this is called
sundowner syndrome? Go to sleep and he’ll leave your apartment.”

Feedback: CORRECT
Rationale: The most therapeutic nursing response is the one that expresses empathy and
helps orient the client to reality. It also offers self, builds trust, and provides support for the
client’s distress. In asking, “Why not just throw him out yourself and lock up once and for
all?” the nurse reinforces the hallucination and delusional thinking by responding as if the
old man is really there. In stating, “Now, you know that you’re always seeing things and
people at night who aren’t there,” the nurse is patronizing and belittling in responding to the
client’s concerns, a nontherapeutic communication. In responding, “I’m sure that you’re
very frightened right now. Do you recall my telling you that this is called sundowner
syndrome? Go to sleep and he’ll leave your apartment,” the nurse is lecturing the client and
giving advice, which is not therapeutic.

Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. The
only option that addresses the client’s fears and feelings is the correct option. Review







22.
A schizophrenic client is seen seemingly talking to someone who isn’t there. Which nursing
statement would be most therapeutic initially?
A) “Today is my birthday. Would you like to go on an outing with my family?”
B) “You need to wash up and get ready to go to supper in the cafeteria with the other clients
now.”
C) “I’ve noticed your eyes darting back and forth, and I wondered whether you might be
hearing voices.”
D) “You were telling me yesterday that your mother died last June of cancer. Can you tell
me more about that?”

Feedback: INCORRECT
Rationale: The most therapeutic nursing statement is the one in which the nurse addresses
the client’s behavior and asks whether the client is hearing voices. With this statement, the
nurse also assesses the client’s behavior. If the client is hearing voices, the nurse prevents
reinforcement of the hallucinatory thinking by telling the client that he or she does not hear
them. In asking, “Today is my birthday. Would you like to go on an outing with my family?”
the nurse nontherapeutically changes the focus from the client. In stating, “You need to
wash up and get ready to go to supper in the cafeteria with the other clients now,” the nurse
ignores the client’s obvious psychotic behavior and directs the client to socialize with others.
Such an intervention is not usually positive, because it floods the client with stimuli that
may contribute to an escalation of psychotic behavior. In asking, “You were telling me
yesterday that your mother died last June of cancer. Can you tell me more about that?” the
nurse uses distraction, summarization, and refocusing.

Test-Taking Strategy: Note the strategic word “initially” and eliminate the options that are
unrelated to the client’s behavior. Also, focus on the data in the question. The correct option
is the only one that addresses the client’s behavior. Review care of the client who is
hallucinating if you had difficulty with this question.







23.
A nurse brings a meal tray to a psychotic client in his hospital room. The client refuses the
meal and says, “I’m not eating any more poisoned food while I’m vacationing here. I’m
starting on a fast to stay healthy and alive.” Which nursing intervention would be most
appropriate initially?
A) Taking the tray away and canceling all meals until further notice
B) Having the client eat with other clients in the community dining room
C) Eating some of the food from the client’s tray to prove that it isn’t poisoned
D) Telling the client that the psychiatrist will be called for a prescription for a tube feeding

Feedback: INCORRECT
Rationale: Having the client eat with other clients in the community room decreases the
amount of time in which the client can stay isolated and engage in suspicious thinking. Of
the options provided, this would be the initial intervention. It does not guarantee that the
client will eat but does reduce the client’s isolation time. Taking the tray away and canceling
all meals until further notice and eating some of the food off the client’s tray to prove that it
isn’t poisoned are both incorrect because they support the client’s delusional thinking.
Telling the client that the psychiatrist will be called for a prescription for a tube feeding is
incorrect because it is a premature action that would lead to a regressive struggle with the
client and is also a threat to the client.

Test-Taking Strategy: Note the strategic word “initially.” First eliminate the option in which
the nurse threatens the client. From the remaining options, eliminate options the options
that are comparable or alike and support the client’s delusional thinking, a nontherapeutic
intervention. Review care of the psychotic client if you had difficulty with this question.







24.
A nurse caring for a schizophrenic client is assessing the client’s ability to control distorted
thought processes. Which of the following findings indicates a positive outcome?

A) The client is able to identify when hallucinations or delusions are real.
B) The client can describe in detail the frequency and context of the hallucinatory and
delusional behavior.
C) The client can describe the hallucinations and delusions in detail and is able to interact
with others and share in their delusional systems.
D) The client can identify the recurrence of hallucinations, can refrain from responding to
them, and reports a significant decrease in the incidence of hallucinations.

Feedback: CORRECT
Rationale: Identifying the reoccurrence of hallucinations, refraining from responding to them,
and reporting a significant decrease in the incidence of hallucinations are all positive client
outcomes. Other positive outcomes include appropriately interacting with others,
demonstrating thinking that is based in reality, and grasping others’ ideas. The other options
are incorrect because they are not positive outcomes with regard to the client’s ability to
control distorted thought processes and focus on the reality of the distorted thought
processes.

Test-Taking Strategy: Use the process of elimination. Focus on the subject, the client’s ability
to control distorted thought processes. The correct option is the only one that identifies
control. Review care of the client who is experiencing distorted thought processes if you had


Cognitive Ability: Evaluating


Integrated Process: Nursing Process/Evaluation



25.
A schizophrenic client says, “I feel like I’m rotting away inside and all of my organs are
rusting.” Which type of delusion does the nurse identify in the client’s statement?
A) Somatic
B) Jealousy
C) Persecution
D) Idea of reference

Feedback: CORRECT
Rationale: Somatic delusions are false beliefs that one’s body is changing in an unusual way,
such as rusting or rotting away. The most therapeutic intervention in such a situation is to
gain the client’s cooperation in taking the antipsychotic medication prescribed by the
psychiatrist. A delusion of jealousy is the false belief that one’s significant other is being

unfaithful. A delusion of persecution is the false belief that one is being singled out for harm
by others. This usually takes the form of a plot by individuals in power against the person. A
client subject to ideas of reference misconstrues trivial events and remarks so that he or
she may attach personal significance to them.

Test-Taking Strategy: Use the process of elimination and your knowledge of the various types
of delusions. Note the data in the question and remember that the client is describing a
physiological manifestation. This will direct you to the correct option. Review the different
types of delusions if you had difficulty with this question.







26.
A schizophrenic client attending a support group held by a clinic nurse says to the nurse and
the group, “I’ve been laid off from my job at the factory, and so have 300 other people, so
I’ll have to get a new job. For now, there’s unemployment.” Which statement by the nurse
would be most therapeutic at this time?
A) “It seems that the stock market is responsible for mass unemployment in our factory-
based city.”
B) “I’m sorry to hear that you’ve lost your job. Why not make an appointment to come in
and talk with me this week?”
C) “How do people feel about this loss of employment? Does anyone in the group who
experienced this have any advice?”
D) “Have other people in the group been feeling the job crunch this week? When changes
like this occur, it’s best to increase the number of your appointments with me for a short
time.”

Feedback: INCORRECT
Rationale: The nurse is leading a support group for schizophrenic clients, so it is important to
address every group member when possible and not single out one member for special
attention. The correct option is open-ended, encourages group sharing of experiences and
support, and teaches the members about the need to increase visits whenever schedules
change abruptly and create stressful situations. In stating, “It seems that the stock market
is responsible for mass unemployment in our factory-based city,” the nurse changes the
focus from feelings and experiences to intellectualize, a nontherapeutic intervention. In
responding, “I’m sorry to hear that you’ve lost your job. Why not make an appointment to
come in and talk with me this week?” the nurse expresses sympathy rather than empathy

and personalizes the invitation for an appointment that may cause jealousy among the other
clients in the group. In asking, “How do people feel about this loss of employment? Does
anyone in the group who experienced this have any advice?” the nurse asks a question of
the group that is off focus.

Test-Taking Strategy: Focus on the environment of the question, a support group. The only
option that addresses all members of the group is the correct option. It is also the umbrella
option. Review the functions of support groups if you had difficulty with this question.







27.
A schizophrenic client arrives for a scheduled appointment with the mental health nurse.
The nurse notes that the client’s hygiene is poor and that the client is having difficulty
concentrating on what the nurse is saying and responding appropriately. Which nursing
intervention would be most appropriate?
A) Saying nothing and contacting the psychiatrist to sign a commitment order
B) Saying, “I notice that you don’t seem to be caring for yourself. Are you taking your
medication?”
C) Giving the client his antipsychotic medication and asking him to return in the morning for
a follow-up visit
D) Asking, “Will you voluntarily admit yourself for a couple of days so that you can
straighten out your medicine and thinking?”

Feedback: CORRECT
Rationale: When the nurse’s observations indicate that the client is noncompliant with his
medicine, the most appropriate intervention is the one in which the nurse makes
observations and assesses noncompliance. Saying nothing and contacting the psychiatrist to
sign a commitment order is inappropriate. Commitment proceedings may be necessary if
the client is a danger to self or others. Giving the client his antipsychotic medication and
asking him to return in the morning for a follow-up visit is inappropriate because the client
needs assessment and intervention immediately. Waiting until the next morning does not
meet the client’s immediate needs. In asking, “Will you voluntarily admit yourself for a
couple of days so that you can straighten out your medicine and thinking?” the nurse asks
the client to enter the hospital voluntarily. This intervention is premature, because further
assessment of the client is needed.

comparable or alike and involve a delay in addressing the client’s needs. To select from the
remaining options, focus on the data in the question and choose the one that addresses
observations made by the nurse. Review care of the schizophrenic client and observations
that indicate medication noncompliance if you had difficulty with this question.

St. Louis: Mosby.






28.
A postpartum client says to the nurse, “Sometimes I hear voices telling me to kill my baby
to save her all the heartache I’ve been through.” Which statement by the nurse would be
most therapeutic?
A) “The voices will disappear in a few weeks as your hormones stabilize.”
B) “This must be very distressing to you. Can you tell me more about the voices?”
C) “It is so good that you shared your feelings and thoughts with me. I’m going to help you
get immediate attention for your voices.”
D) “You will want to tell the doctor about them when you visit him next week. He is very
interested in these voices and will want to help you with them.”

Feedback: INCORRECT
Rationale: The client is experiencing serious postpartum psychosis and command
hallucinations. They require immediate medical attention and intervention for the protection
of both the mother and her baby. In stating, “The voices will disappear in a few weeks as
your hormones stabilize,” the nurse disregards serious clinical manifestations. In
responding, “This must be very distressing to you. Can you tell me more about the voices?”
the nurse is trying to obtain additional data, but the client’s statement indicates a
psychiatric emergency that requires immediate intervention. In stating, “You will want to tell
the doctor about them when you visit him next week. He is very interested in these voices
and will want to help you with them,” the nurse delays and refers the client to a psychiatrist
1 week from now, an intervention that may be too late for the mother and baby.

Test-Taking Strategy: Focus on the words “voices telling me to kill my baby.” The only option
that provides immediate attention to this serious statement is the correct option. Review
interventions for the client who indicates the possibility of self-harm or harm to others if you

Louis: Mosby.






29.
A schizophrenic client exhibits confused and unintelligible speech. Which nursing statement
would be most therapeutic?
A) “Got it. The ‘blinks’ are ‘taking over’ the ‘bumpers.’”
B) “I can’t understand what you’re saying. You have to talk more clearly!”
C) “This morning you are participating in the tree-decorating ceremony for the unit.”
D) “I can’t understand you. Are you asking me to stay with you while you eat supper?”

Feedback: CORRECT
Rationale: The most therapeutic technique for assisting a client whose speech is confused
and unintelligible is to emphasize what is happening in the here and now and involve the
client in simple reality-based activities. “Got it. The ‘blinks’ are ‘taking over’ the ‘bumpers’”
is unintelligible speech on the part of the nurse and reinforces the client’s behavior. In
stating, “I can’t understand what you’re saying. You have to talk more clearly!” the nurse
begins with an appropriate response, but demanding that the client speak more clearly is
inappropriate. In responding, “I can’t understand you. Are you asking me to stay with you
while you eat supper?” the nurse is guessing at what the client has said.

Test-Taking Strategy: Use the process of elimination. First eliminate the option that is
unintelligible. Next eliminate the option that is demanding that the client speak more clearly.
As you choose from the remaining options, remember that a schizophrenic client who
exhibits confusion and unintelligible speech should be involved in simple reality-based
activities. Review care of the client with schizophrenia if you had difficulty with this
question.

Louis: Mosby.






30.
A schizophrenic client says to the nurse, “I keep getting these thoughts and hearing voices.
They worry and consume me so that I can’t always stop myself like my doctor told me to.”
Which intervention would the nurse suggest as a distraction technique?
A) “Pretend that you’re on the phone and talk to the voices.”
B) “Have you tried to count back from 100 or listen to music?”
C) “The next time this happens, try telling the voices to go away.”
D) “Tell the voices that you will only listen to them just before you watch television at 8:30
in the evening.”

Feedback: CORRECT
Rationale: Distracting ways of coping with voices include reading aloud, describing an object
in detail, listening to music, and watching television. Having the client try to count back
from 100 or listen to music will assist in distraction. In the remaining options, the nurse
suggests interacting techniques that reinforce the client’s belief that the voices are real.

comparable or alike and indicate that the voices are real. Review care of the schizophrenic
client who is hallucinating if you had difficulty with this question.







31.
A nurse plans outcomes for a client who is being treated for psychosis. Which of the
following steps would be included during the stable or discharge phase of treatment?
A) Evaluation of neurological status
B) Use of directive communications with the client
C) Administration of acute psychotropic medications
D) Keeping the client active with hobbies, exercise, and work

Feedback: INCORRECT
Rationale: Desired outcomes for a psychotic client during the stable or discharge phase of
treatment include maintenance of a consistent sleeping pattern; avoidance of caffeine and
alcohol; maintenance of daily and weekly routines, including enjoyable activities; and a
regular medication schedule. Evaluation of neurological status, the use of directive
communications, and the administration of acute psychotropic medications with the client
are all active-phase interventions.

Test-Taking Strategy: Use the process of elimination and focus on the subject, the stable or
discharge phase of treatment. First eliminate the option that contains the word “acute.” To
select from the remaining options, focus on the subject. Evaluation of neurological status
and use of directive communications with the client are part of the acute phase of
treatment. Review interventions for the client with psychosis who is preparing for discharge
if you had difficulty with this question.

St. Louis: Mosby.






32.
A schizophrenic client is admitted to the inpatient psychiatric unit. The client is exhibiting
clang associations, word salad, and loose associations. Which problem does the nurse
recognize that the client is experiencing?
A) Defensive coping
B) Inability to cope effectively
C) Sensory perception alterations
D) Inability to communicate effectively

Feedback: CORRECT
Rationale: Clang associations, word salad, and loose associations are language disturbances
that indicate a client’s inability to communicate effectively. These manifestations are not
associated with coping or sensory alterations.

Test-Taking Strategy: Focus on the data in the question. Eliminate the options that are
comparable or alike: Defensive coping is the same as inability to cope effectively. To select
from the remaining options, recall that clang associations, word salad, and loose

associations are signs of disturbed thought process and impaired verbal communication,
which will direct you to the correct option. Review the characteristics of schizophrenia if you

St. Louis: Mosby.






33.
A 24-year-old schizophrenic client says, “I was in college and suddenly I was hearing voices
telling me I was no good and that I should jump off the bridge by our college. My parents
came and got me when I called them. We thought that I had inadvertently taken drugs at a
party or something. My psychiatrist says that if I can improve, I can return to college next
semester.” Which of the following guidelines does the nurse plan to incorporate into teaching
of the client and family about self-care on the client’s return to college?
A) Compliance with the treatment regimen, immediate reporting of any relapse signs,
avoidance of alcohol and drugs, and living a balanced lifestyle
B) Telling all friends about the illness so that they support the client’s avoidance of alcohol
and drugs and help the client maintain a balanced lifestyle
C) Limiting college attendance to commuter status to maintain a supportive family group
and avoiding drugs, alcohol, and the strain of socialization
D) Compliance with treatment, immediate reporting of any relapse signs, avoidance of
alcohol and drugs, and socialization with one supportive friend

Feedback: CORRECT
Rationale: Self-care guidelines for the client include compliance with the treatment regimen,
immediate reporting of any relapse signs, avoidance of alcohol and drugs, and living a
balanced lifestyle. Telling all friends about the illness so that they can support the client’s
avoidance of alcohol and drugs and help the client maintain a balanced lifestyle is incorrect.
Although the closest supportive friends need to know and understand the illness, not
everybody does. Limiting college attendance to commuter status to maintain a supportive
family group and avoiding drugs, alcohol, and the strain of socialization is incorrect. Not
allowing the client to be independent and follow a normal growth and development pattern
would retard the client’s growth. Socializing with one supportive friend is incorrect because
it is best to bring as many supportive persons to the client as possible.

Test-Taking Strategy: Use the process of elimination and focus on the data in the question
and the subject, self-care. Eliminate the options that contain the words “one,” “all,” and
“limiting". Also note that the correct option is the umbrella option. Review care of the client
with schizophrenia if you had difficulty with this question.




Integrated Process: Teaching and Learning



34.
A schizophrenic client in the psychiatric inpatient unit is yelling, “The CIA is trying to kill me.
I know they’re plotting to kill me so they can overthrow the government.” On the basis of
the client’s statement, which clinical manifestation would the nurse document in the client
record?
A) Demonstrates paranoia
B) Exhibits ideas of reference
C) Evidence of persecutory delusions
D) Evidence of ideas of somatic delusions

Feedback: CORRECT
Rationale: A persecutory delusion is the false belief that one is being singled out for harm by
others, generally in the form of a plot by other people against the client. Paranoia is an
intense and strongly defended irrational suspicion. An idea of reference is the misconstruing
of trivial events in order to give them personal significance. A somatic delusion is the false
belief that the body is changing in an unusual way (e.g., rotting inside).

Test-Taking Strategy: Use the process of elimination. Focus on the client’s statement and
note the relationship between the words “trying to kill me” in the question and
“persecutory” in the correct option. Review the characteristics of schizophrenia if you had


Cognitive Ability: Understanding





35.
A manic client who tends to be manipulative says angrily, “You had better let me out of
here, or I’m going to call my lawyer. My boss has good friends with the owners of this tin-
pot place you call a ‘mind holism respite.’” Which statement by the nurse would be most
therapeutic?
A) “When you can speak to me without yelling and being aggressive, I’ll be happy to speak
with you.”
B) “Just get your anger out with me, because we’re not going to allow you be discharged
until you calm down.”
C) “Do threats and name-calling usually work for you? Do people tend to listen to you and
do as you order them to?”
D) “I know that you feel that you’re doing your very best right now, but you are yelling.
Take some time out and some deep breaths, and I’ll speak to you in half an hour.”

Feedback: INCORRECT
Rationale: Anger is an emotional response to the perception of frustration of desires, threat
to one’s needs (emotional or physical), or a challenge. It reflects rage, hostility, and the
potential for physical or verbal destructiveness. With manipulative clients, solutions that
provide options and empathy work best. An authoritarian style in which the nurse labels
aggression is inappropriate and is not effective with such clients. Additionally, the remaining
options may further anger the client and escalate the client’s behavior.

comparable or alike and may further anger the client. Also note that the correct option
provides praise to the client and provides an option for dealing with the client’s behavior.
Review interventions to defuse anger if you had difficulty with this question.







36.
A client in a mental health unit gets into a fight with another client over the use of the public
telephone on the unit. The client is accused of making two telephone calls and staying on
the telephone for 1 hour. Which of the following interventions by the nurse would be most
therapeutic?
A) Taking telephone privileges away from both clients for the day and giving them time-outs
in their rooms
B) Saying to the clients, “Okay, this is the last straw. Neither of you may use the telephone
until tomorrow, and then only with a nurse timing you.”
C) Saying to the clients, “Go to your rooms, both of you. I don’t want to hear anything more
about the telephone on this unit for at least 2 hours.”
D) Saying to the clients, “You may each use the phone for 10 minutes. I will time the calls
for both of you. Do you both agree to abide by my decision?”

Feedback: CORRECT
Rationale: The most therapeutic intervention is the one in which the nurse gives an
alternative solution and asks for the clients’ cooperation. If this approach fails, the nurse
must eliminate the phone privilege for both clients and give time-outs to deescalate the
situation.Taking telephone privileges away from both clients for the day and giving them
time-outs in their rooms is nontherapeutic because the nurse is not being empathetic. In
stating, “Okay, this is the last straw. Neither of you may use the telephone until tomorrow,
and then only with a nurse timing you,” the nurse displays anger and is nontherapeutic in
punishing the clients. In responding, “Go to your rooms, both of you. I don’t want to hear
anything more about the telephone on this unit for at least 2 hours,” the nurse is
nontherapeutically authoritarian and does not provide empathy.

comparable or alike in that the nurse acts in a punishing and authoritarian way. Also, note
that the correct option is the only option that provides an alternative solution for both
clients. Review measures for dealing with an angry client if you had difficulty with this
question.







37.

A nursing instructor enters a classroom to begin class and finds two students yelling and
physically assaulting each other. Which intervention by the instructor would be most
appropriate?
A) Walking out of the classroom and asking the secretary to call security, then telling all of
the students to leave and go to the nursing laboratory
B) Getting the class to leave with her and sending everyone to the nursing laboratory, then
calling security to the classroom and reentering to observe what is happening with the two
students.
C) Telling the class, “Take a break. I’ll come and get you to restart class as soon as I can,”
then closing the classroom door, refusing to let anyone else in, and asking a passing
instructor to get security
D) Telling the class to go to the nursing laboratory at once, then asking a student to tell the
nursing secretary to have security come to the classroom, and asking the students who are
fighting to stop fighting and take their seats

Feedback: CORRECT
Rationale: The first concern is to ensure student safety, so in the correct option the students
are directed to go to the nursing laboratory. Someone is asked to notify security, and then
the instructor determines whether the students who are fighting can obey the direction to
stop and take a seat. Leaving the classroom without attempting to verbally direct the
students to stop fighting results in an unsafe environment for the students who are fighting.
Although closing the classroom door might be helpful in discouraging other students from
watching the fight, it is not generally considered a safe intervention to bar access to an exit
when violence has erupted.

Test-Taking Strategy: Focus on the information in the question and recall that safety is the
priority. The correct option is the only one that provides safety to all involved. Review
interventions for a violent situation if you had difficulty with this question.







38.
A student calls the campus crisis hotline and tells the nurse, “I went out to a sorority party
last week and drank too much. Someone raped me, but when I told my folks about it, they
acted like it was my fault. I feel so dirty and used.” Which statement by the nurse would be
most therapeutic?
A) “Would you come in to talk with me in the strictest confidence?”

B) “I believe that you can feel a lot better about yourself. Won’t you come in to see me
tomorrow?”
C) “Parents always feel that their daughters could never be raped. I could talk to them for
you, if you’ll let me.”
D) “You’ve had an awful experience, but it’s not your fault that it happened. Can you come
in and talk to me about it in more detail?”

Feedback: CORRECT
Rationale: Rape is vaginal or anal penetration against the victim’s will and consent. The
student is in crisis and needs counseling. Her call seems to be the result of her being unable
to turn to her parents as she might have been able to in the past. The nurse needs to let
the student know that the rape was not her fault. Many students overdrink but are not
raped just because they were inebriated. By asking, “Would you come in to talk with me in
the strictest confidence?” the nurse assures confidentiality, but this option is nontherapeutic
because a bridge of trust has not yet been established with the client. In responding, “I
believe that you can feel a lot better about yourself. Won’t you come in to see me
tomorrow?” the nurse offers opinions on outcomes and delays treatment, which is
nontherapeutic. In responding, “Parents always feel that their daughter could never be
raped. I could talk to them for you, if you'll let me,” the nurse lectures the student on why
her parents are not supportive without ever having met them. This answer is nontherapeutic
and insensitive.

Test-Taking Strategy: Use the process of elimination and your knowledge of therapeutic
communication techniques. The correct option, the umbrella option, acknowledges the
client’s experience, informs the client that the rape was not her fault, expresses support,
and provides immediate treatment. Review interventions for the client who is a victim of
abuse if you had difficulty with this question.







39.
A psychiatric nurse is playing a card game with a client in the day room. The client states to
the nurse, "The voice in my head is telling me that you're cheating." Which of the following
responses by the nurse is therapeutic?
A) "I do not hear any voices. Has the voice said anything else?"
B) "Is the voice telling you to do anything?"
C) "It isn't possible for people to hear voices in their head."

D) "I don't believe that you are hearing voices."

Feedback: INCORRECT
Rationale: When caring for a client experiencing delusions or hallucinations, the nurse should
listen to the client, present reality, and collect more data regarding the content of the
delusion and/or hallucination. Stating, "I do not hear any voices. Has the voice said
anything else?" is correct because it presents reality and collects more data from the client.
Although stating, "Is the voice telling you to do anything?" collects more data, it does not
present reality. Stating, "It isn't possible for people to hear voices in their head" and "I don't
believe that you are hearing voices" are non-therapeutic and do not address the needs or
feelings of the client.

Test-Taking Strategy: Use therapeutic communication techniques to answer this question.
Recalling that it is important to both present reality and collect more data from a client
actively experiencing delusions and/or hallucinations will assist in directing you to the
correct option. Review therapeutic communication techniques if you had difficulty with this
question.

Reference: Vacarolis, E. M., & Halter, M. J. (2010). Foundations of psychiatric mental health
nursing. (6th ed., p. 323). St. Louis: Saunders.






40.
A client says to the nurse, “I’m really phobic about flying, so my husband and I always
drove or took the train everywhere. Now he’s been offered a big job in Europe, and if I don’t
get over this and fly with him, he says we’re done. I’ll be left to bring up our three children
by myself.” Which statement by the nurse would be therapeutic?
A) “No problem. You can be hypnotized to sleep through your trip.”
B) “I’m interested that it took his threat of leaving you to motivate you to seek help.”
C) “You seem more anxious and afraid of raising three children alone than of flying.”
D) “I can teach you strategies to help master your panic. An antianxiety medicine would
also help you.”

Feedback: CORRECT
Rationale: A phobia is a persistent, irrational fear of a specific object, activity, or situation
that leads to a desire for avoidance or actual avoidance of the object, activity, or situation.
The nurse can teach strategies, such as relaxation training and thought-stopping, to help
the client master her anxiety. There are also medications that the psychiatrist can prescribe

to help ease the client’s phobia. In stating, “No problem. You can be hypnotized to sleep
through your trip,” the nurse provides false reassurance and belittles the client’s worries and
fears. In responding, “I’m interested that it took his threat of leaving you to motivate you to
seek help,” the nurse uses a nontherapeutic change of subject that can only increase the
client’s anxiety and fear. This response also lowers the client’s trust in her relationship with
the nurse. In stating, “You seem more anxious and afraid of raising three children alone
than of flying,” the nurse changes the subject.

Test-Taking Strategy: Use the process of elimination and therapeutic communication
techniques. Eliminate the options that do not focus on the client’s concern or provide false
reassurance. The correct option is focused on the client’s concern and provides a reasonable
solution. Review therapeutic communication techniques if you had difficulty with this
question.







41.
A nurse is trying to deescalate aggressive behavior exhibited by a client with schizophrenia.
Which nursing action would be contraindicated in this situation?
A) Being assertive with the client
B) Negotiating options with the client
C) Maintaining a nonaggressive posture
D) Standing close to the client and telling the client that the behavior is unacceptable

Feedback: INCORRECT
Rationale: To deescalate aggressive behavior, the nurse should maintain calm and a
nonaggressive posture. The nurse should also give the client clear instructions that are brief
and assertive and negotiate options with the client. Negotiation of options allows the client
to feel that he or she has some room in making decisions. The nurse needs to maintain
personal space and should not stand closer than about 8 feet from the client, which would
convey a threatening message.

Test-Taking Strategy: Focus on the subject, deescalation of aggressive behavior, and note the
strategic word “contraindicated.” Visualize each of the options in terms of how it might

protect or threaten the client. This will direct you to the correct option. If you had difficulty
with this question, review measures to deescalate aggressive behavior.







42.
A client is scheduled to undergo electroconvulsive therapy (ECT). Which client concern is of
the highest priority?
A) Fear
B) Anxiety
C) Distorted body image
D) Risk for impaired breathing

Feedback: CORRECT
Rationale: NPO status for 6 to 8 hours before a procedure, removal of dentures during the
procedure, and administration of medication as prescribed to diminish oral secretions are all
safeguards against aspiration during ECT. Although fear and anxiety could also be concerns,
they are not the most important ones. There is no reason to infer that distorted body image
is a consideration.

Test-Taking Strategy: Use Maslow's Hierarchy of Needs theory to answer the question.
Physiological needs are the priority, so select the option that addresses these needs.
Additionally, remember the ABCs— airway, breathing, and circulation. Airway is the concern
with the risk of aspiration. If you had difficulty with this question, review procedures related
to ECT.

Louis: Mosby.


Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Analysis



43.
The mother of a child who is taking methylphenidate hydrochloride (Ritalin) tells the school
nurse that she is administering an over-the-counter (OTC) cough syrup to her son. Which
response by the nurse would be appropriate?
A) “His cough could be a side effect of the Ritalin.”
B) “Your son should never take any medicine, even if it’s OTC.”
C) “You may administer a small amount of OTC cough syrup without a problem, but not for
more than 3 days.”
D) “I think that you should stop giving this medicine to your son until I can check its content
with the pharmacy.”

Feedback: CORRECT
Rationale: When a client is taking methylphenidate hydrochloride (Ritalin), no OTC
medications should be administered without the approval of the pharmacist or physician.
Such medications could contain caffeine, which must be avoided. In stating, “Your son
should never take any medicine, even if it’s OTC,” the nurse is lecturing and belittling. In
stating, “His cough could be a side effect of the Ritalin” or “You may administer a small
amount of OTC cough syrup without a problem, but not for more than 3 days,” the nurse
provides inaccurate information.

Test-Taking Strategy: Use the process of elimination. Eliminate the option that contains the
closed-ended word “never.” To select from the remaining options, recall that OTC
medications should not be taken by clients taking prescription medications without the
approval of the physician. Review the contraindications associated with this medication if
you had difficulty with this question.

Reference: Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2010. (p. 737).
St. Louis: Saunders.






44.

A nurse notices a paranoid stare during a conversation with a client. The client then begins
to fidget and gets up to pace around the room. Which of the following actions by the nurse
would be beneficial?
A) Allowing the client to pace
B) Escorting the client to a quiet room
C) Changing the conversation to a less threatening subject
D) Sharing the observation with the client and helping the client recognize and acknowledge
his or her feelings

Feedback: INCORRECT
Rationale: Sharing observations with clients may help them recognize and acknowledge their
feelings. Moving the client to a quiet room or changing the subject will not help a client
recognize his or her behaviors and feelings. Allowing the client to pace provides no
assistance and may lead to their becoming out of control.

Test-Taking Strategy: Use the process of elimination and therapeutic communication
techniques. Eliminate the options that do not address the client’s behavior. Remembering
that the sharing observations with the client and helping the client recognize and
acknowledge his or her feelings will be of help to the client who is experiencing paranoid
behaviors. Review care of the paranoid client if you had difficulty with this question.







45.
A nurse working in a mental health unit reads a client’s medical record and notes
documentation that the client has been experiencing flashbacks. The nurse interprets this as
a classic sign of:
A) Depression
B) Schizophrenia
C) Post–traumatic stress disorder
D) Obsessive-compulsive disorder

Feedback: CORRECT
Rationale: Flashbacks are the classic manifestation of post–traumatic stress disorder, or
PTSD, and are not associated with depression, obsessive-compulsive disorder, or
schizophrenia.

Test-Taking Strategy: Use the process of elimination and note the strategic word
“flashbacks.” Review each option and think about the manifestations of each disorder to
answer correctly. Review the manifestations of each of these disorders if you had difficulty
with this question.







46.
A client arrives in the emergency department in a crisis state. The client demonstrates signs
of profound anxiety and is unable to focus on anything but the object of the crisis and the
impact on herself. The nurse plans to focus the initial assessment on:
A) Sources of support
B) The object of the crisis
C) The client’s coping mechanisms
D) The physical condition of the client

Feedback: INCORRECT
Rationale: The initial priority in the nursing assessment of a client in a crisis state is to
assess physical condition, potential for self-harm, and potential for harm to others. Once
these questions have been answered and the appropriate interventions have been initiated,
the nurse may proceed in providing psychosocial care.

Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory. Physiological needs take
priority over other needs. The correct option is the only option that addresses a
physiological need. Review care of the client in crisis if you had difficulty with this question.







47.
A nurse has been closely observing a client who has been displaying aggressive behaviors
and notes that the client’s aggressiveness is escalating. Which nursing intervention would be
least helpful to this client at this time?
A) Initiating confinement measures
B) Acknowledging the client’s behavior
C) Assisting the client to an area that is quiet
D) Maintaining a safe distance with the client

Feedback: INCORRECT
Rationale: During the escalation period, the client’s behavior is moving toward loss of
control. Nursing actions include taking control, maintaining a safe distance, acknowledging
the behavior, moving the client to a quiet area, and medicating the client as appropriate. It
is not appropriate during this period to initiate confinement measures; this action is most
appropriate during the crisis period.

Test-Taking Strategy: Note the strategic words “least helpful” and focus on the data in the
question. Nursing actions will vary depending on the level of aggressive behavior that the
client is exhibiting. Knowledge of these levels and the appropriate nursing actions is
required to answer this question. However, focusing on the strategic words will direct you to
the correct option. Review care of the client exhibiting aggressive behavior if you had







48.
A nurse is assigned to care for a client experiencing a crisis. What is the appropriate initial
nursing intervention for this client?
A) Providing authority and action
B) Displaying an attitude of detachment and efficiency
C) Providing hope and reassurance that the crisis is temporary

D) Demonstrating confidence in the client’s ability to deal with the crisis

Feedback: INCORRECT
Rationale: A crisis is an acute time-limited state of disequilibrium resulting from situational,
developmental, or societal sources of stress. A person in this state is temporarily unable to
cope with or adapt to the stressor with the use of previously successful problem-solving
methods. Someone who intervenes in this situation (the nurse) takes over for the client who
is not in control and devises a plan (action) to secure and maintain the client’s safety. The
nurse then works collaboratively with the client, demonstrating confidence in the client’s
ability to cope and providing reassurance that the crisis is temporary. Displaying an attitude
of detachment is inappropriate.

Test-Taking Strategy: Use the process of elimination and note the strategic word “initial.” The
client who experiences a crisis is in acute disequilibrium. Remember, in a crisis, an authority
figure must emerge to take action. Review crisis intervention and the nurse’s responsibilities
if you had difficulty with this question.







49.
A home care nurse makes a visit to a client with a diagnosis of depression. The nurse finds
the client unconscious on the floor, with an empty bottle of a prescribed tricyclic
antidepressant lying near the client. What action must the nurse take immediately?
A) Inducing vomiting
B) Calling an ambulance
C) Administering syrup of ipecac
D) Counting the pills remaining in the bottle

Feedback: CORRECT
Rationale: An overdose of a tricyclic antidepressant can be fatal, regardless of the amount
ingested. Serious life-threatening symptoms may develop after an overdose. Immediate
emergency medical attention and cardiac monitoring are needed in the event of an overdose
of a tricyclic antidepressant. The nurse would not induce vomiting or administer anything by
way of the oral route if the client is unconscious. Counting the remaining pills provides no
useful information and delays necessary and immediate intervention. Additionally, the
question notes that the bottle of pills is empty.

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