Option C, which also encourages a yes or no
Answers and Rationale
1. Answer: D. Use the services of an interpreter.
An interpreter will enable the nurse to better assess the clients
problems and concerns.
Option A: Nonverbal communication is important;
however for the nurse to fully determine the clients problems
and concerns, the assistance of an interpreter is essential.
Options B and C: The use of symbolic pictures and
universal phrases may assist the nurse in understanding the
basic needs of the client; however these are insufficient to
assess the client with a psychiatric problem.
2. Answer: D. Psychoanalytic theory
Psychoanalytic is based on Freuds beliefs regarding the
importance of unconscious motivation for behavior and the role
of the id and superego in opposition to each other.
Options A and B: Behavioral cognitive and
interpersonal theories do not emphasize unconscious conflicts
as the basis for symptomatic behavior.
3. Answer: D. I notice that youre pacing. How are you
feeling?
By acknowledging the observed behavior and asking the client
to express his feelings the nurse can best assist the client to
become aware of his anxiety.
In option A, the nurse is offering an interpretation that
may or may not be accurate; the nurse is also asking a
question that may be answered by a yes or no response,
which is not therapeutic.
In option B, the nurse is intervening before accurately
assessing the problem.
response, avoids focusing on the clients anxiety, which is the
reason for his pacing.
4. Answer: A. Accepting the clients obsessive-compulsive
behaviors
A client with obsessive-compulsive behavior uses this behavior
to decrease anxiety. Accepting this behavior as the clients
attempt to feel secure is therapeutic. When a specific treatment
plan is developed, other nursing responses may also be
acceptable.
Options B, C, and D: The remaining answer choices
will increase the clients anxiety and therefore are
inappropriate.
5. Answer: A. Education and work history
Education and work history would have the least significance in
relation to the clients sexual problem.
Options B, C, and D: Age, health status, physical
attributes and relationship issues have great influence on
sexual expression.
6. Answer: C. Help establish a plan using privileges and
restrictions based on compliance with refeeding.
Inpatient treatment of a client with anorexia usually focuses
initially on establishing a plan for refeeding to combat the
effects of self-induced starvation. Refeeding is accomplished
through behavioral therapy, which uses a system of rewards
and reinforcements to assist in establishing weight restoration.
Options A and D: Emphasizing nutrition and teaching
the client about the long-term physical consequences of
anorexia maybe appropriate at a later time in the treatment
program.
 Option B: The nurse needs to assess the clients Option D: Indirect questions convey to the client that

mealtime behavior continually to evaluate treatment the nurse is not comfortable with the subject of suicide and,

effectiveness. therefore, the client may be reluctant to discuss the topic.

7. Answer: A. The parents reinforce increased decision 10. Answer: C. The client speaks in coherent sentences

making by the client.

A client exhibiting flight of ideas typically has a continuous

One of the core issues concerning the family of a client with speech flow and jumps from one topic to another. Speaking in

anorexia is control. The familys acceptance of the clients coherent sentences is an indicator that the clients

ability to make independent decisions is key to successful concentration has improved and his thoughts are no longer

family intervention. racing.

Options B, C, and D: Although the remaining options Options A, B, and D: The remaining options do not

may occur during the process of therapy they would not relate directly to the stated nursing diagnosis.

necessarily indicate a successful outcome; the central family

issues of dependence and independence are not addressed in 11. Answer: C. Risk for self-directed violence

these responses.
The nurse should take any nurse statements indicating suicidal

8. Answer: D. The client will express anxiety verbally thoughts seriously and further assess for other risk factors.

rather than through physical symptoms.

Options A, B, and D: The remaining diagnoses fail to

The client with a somatoform disorder displaces anxiety into address the seriousness of the clients statement.

physical symptoms. The ability to express anxiety verbally

12. Answer: D. The distressing symptoms of this disorder
indicates a positive change toward improved health.
can respond to treatment with medications.

Options A, B, and C: The remaining responses do not

This statement provides accurate information and an element
indicate any positive change toward increased coping with
of hope for the family of a schizophrenic client.
anxiety.

Options A, B, and C: Although the remaining

9. Answer: C. Question the client directly about suicidal
statements are true, they do not provide the empathic response
thoughts.
the family needs after just learning about the diagnosis. These

Directly questioning a client about suicide is important to facts can become part of the ongoing teaching.

determine suicide risk.

13. Answer: A. The client will demonstrate realistic

Option A: The client may not bring up this subject for interpretation of daily events in the unit.

several reasons, including guilt regarding suicide, wishing not

A client with schizophrenia, paranoid type, has distorted
to be discovered, and his lack of trust in staff.
perceptions and views people, institutions, and aspects of the
Option B: Behavioral cues are important, but direct
environment as plotting against him. The desired outcome for
questioning is essential to determine suicide risk.
someone with delusional perceptions would be to have a

realistic interpretation of daily events.

 Option B: The client with a distorted perception of the Option C: Deterioration in social functioning,

environment would not necessarily have impairments affecting excessive anxiety and worry and bizarre behaviors are typical

hygiene and grooming skills. in schizophrenic disorders.

Options C and D: Although taking medications and Option D: Sadness, poor appetite, sleeplessness, and

participating in unit activities may be appropriate outcomes for loss of interest in activities are behaviors commonly seen in

nursing intervention; these responses are not related to client depressive disorders.

perceptions.
17. Answer: B. Heroin dependence.

14. Answer: D. Risk for other-directed violence

Babies born to heroin-dependent women are also heroin-

A client with these symptoms would have poor impulse control dependent and need to go through withdrawal. There is no

and would therefore be prone to acting-out behavior that may evidence to support any of the remaining answer choices.

be harmful to either himself or others. All of the remaining

nursing diagnoses may apply to the client with mania; however, 18. Answer: D. Ensure an unbroken chain of evidence.

the priority diagnosis would be risk for violence.

Establishing an unbroken chain of evidence is essential in

Options A, B, and C: All of the remaining nursing order to ensure that the prosecution of the perpetrator can

diagnoses may apply to the client with mania; however, the occur.

priority diagnosis would be risk for violence.

Options A and D: The nurse will also need to preserve

15. Answer: C. Rationalization the clients privacy and identify the extent of an injury. However,

it is essential that the nurse follows legal and agency

Rationalization is the defense mechanism that involves offering guidelines for preserving evidence.

excuses for maladaptive behavior. The client is defending his Option C: Identifying the assailant is the job of law

substance abuse by providing reasons related to life stressors. enforcement, not the nurse.

This is a common defense mechanism used by clients with

substance abuse problems. 19. Answer: D. The familys socioeconomic status

Options A, B, and D: None of the remaining defense Socioeconomic status is not a reliable predictor of abuse in the

mechanisms involves making excuses for behaviors. home so that it would be the least important consideration in

deciding issues of safety for the victim of family violence.

16. Answer: B. Physical aggressiveness, low-stress

tolerance disregard for the rights of others Options A and B: The availability of appropriate

community shelters and the ability of the non-abusing caretaker

Physical aggressiveness, low-stress tolerance, and a disregard to intervene on the clients behalf are important factors when

for the rights of others are common behaviors in clients with making safety decisions.

conduct disorders. Option C: The clients response to possible relocation

(if the client is a competent adult) would be the most important

Option A: Restlessness, short attention span, and factor to consider; feelings of empowerment and being treated
hyperactivity are typical behaviors in a client with attention as a competent person can help a client feel less like a victim.
deficit hyperactivity disorder.
20. Answer: A. Balancing a checkbook.
 In the early stage of Alzheimers disease, complex tasks (such determining why the client considers this a crisis and whether

as balancing a checkbook) would be the first cognitive deficit to he can meet his present needs.

occur.
24. Answer: D. Returns to his previous level of functioning.

Options B, C, and D: The loss of self-care ability,

problems with relating to family members, and difficulty Crisis intervention is based on the idea that a crisis is a

remembering ones own name are all areas of cognitive decline disturbance in homeostasis (steady state). The goal is to help

that occur later in the disease process. the client return to a previous level of equilibrium in functioning.

21. Answer: C. Reduce environmental stimuli to redirect Options A, B, and C: The remaining answer choices

the clients attention. are not considered the primary outcome of crisis intervention,

although they may occur as a side benefit.

The client with Alzheimers disease can have frequent episode

of labile mood, which can best be handled by decreasing a 25. Answer: B. Initiation phase

stimulating environment and redirecting the clients attention.

Increased anxiety and uncertainty characterize the initiation

Option A: The client with Alzheimers disease loses phase in group therapy. Group members are more self-reliant

the cognitive ability to respond to either humor or logic. during the working and termination phases.

Option B: An over stimulating environment may cause

26. Answer: A. Decide to continue.
the labile mood, which will be difficult for the client to

understand.
As the group progresses into the working phase, group
Option D: The client lacks any insight into his or her
members assume more responsibility for the group. The leader
own behavior and therefore will be unaware of any causative
becomes more of a facilitator. Comments about behavior in a
factors.
group are indicators that the group is active and involved.

22. Answer: A. Acetylcholine

Options B, C, and D: The remaining answer choices

would indicate the group progress has not advanced to the

A relative deficiency of acetylcholine is associated with this
working phase.
disorder. The drugs used in the early stages of Alzheimers

disease will act to increase available acetylcholine in the brain.

27. Answer: C. Diuretics
The remaining neurotransmitters have not been implicated in

Alzheimers disease. The use of diuretics would cause sodium and water excretion,

which would increase the risk of lithium toxicity. Clients taking

23. Answer: C. The clients perception of the triggering
lithium carbonate should be taught to increase their fluid intake
event and availability of situational supports
and to maintain normal intake of sodium.

The most important factors to determine in this situations are

Options A, B, and D: Concurrent use of any of the
the clients perception of the crisis event and the availability of
remaining medications will not increase the risk of lithium
support (including family and friends) to provide basic needs.
toxicity.

Options A, B, and D: Although the nurse should

28. Answer: D. Parental disagreement
assess the other factors, they are not as essential as
 In a functional family, parents typically do not agree on all
issues and problems. Open discussion of thoughts and feeling
is healthy, and parental disagreement should not cause system
stress.
Options A, B, and C: The remaining answer choices
are life transitions that are expected to increase family stress.
29. Answer: A. Aged cheese and red wine
Aged cheese and red wines contain the substance tyramine
which, when taken with an MAOI, can precipitate a
hypertensive crisis.
Options B, C, and D: The other foods and beverages do not
contain significant amounts of tyramine and, therefore, are not
restricted.
30. Answer: C. Take the clients blood pressure
Because chlorpromazine (Thorazine) can cause a significant
hypotensive effect (and possible client injury), the nurse must
assess the clients blood pressure (lying, sitting, and standing)
before administering this drug.
Option A: If the client had taken the drug previously,
the nurse would also need to assess the skin color and sclera
for signs of jaundice, a possible drug side affect; however,
based on the information given here, there is no evidence that
the client has received chlorpromazine before.
Option D: Although the drug can cause urine
retention, asking the client to avoid will not alter this
anticholinergic effect.
31. Answer: B. Depression.
The onset of action of the SSRI antidepressant paroxetine
occurs around 3 to 4 weeks after drug therapy begins.
Therefore, a client will seldom notice improvement before this
time. Continuing to take the drug is important for this client.
32. Answer: B. Diphenhydramine (Benadryl)
Over-the-counter medications used for allergies and cold
symptoms are contraindicated because they will increase the
sympathomimetic effects of MAOIs, possibly causing a
hypertensive crisis.
Options A, C, and D: None of the remaining
medications will increase the sympathomimetic response and,
therefore, are not contraindicated.
33. Answer: C. Report incomplete bladder emptying
Urinary retention is a common anticholinergic side effect of
psychotic medications, and the client with benign prostatic
hypertrophy would have increased risk for this problem.
Options A and B: Adding fiber to ones diet and
exercising regularly are measures to counteract another
anticholinergic effect, constipation.
Option D: Depending on the specific medication and
how it is prescribed, taking the medication at night may or may
not be important. However, it would have nothing to do
with urinary retention in this client.
34. Answer: B. Coffee
Coffee contains caffeine, which has a stimulating effect on the
central nervous system that will counteract the effect of the
antianxiety medication oxazepam. None of the remaining foods
is contraindicated.
35. Answer: B. Help members maintain sobriety.
The primary purpose of Alcoholics Anonymous is to help
members achieve and maintain sobriety.
Options A, C, and D: Although each of the remaining
answer choices may be an outcome of attendance at
Alcoholics Anonymous, the primary purpose is directed toward
sobriety of members.
36. Answer: C. The client demonstrates self-reliance and
social adaptation.
 A therapeutic community is designed to help individuals Option B: Delirium is a type of cognitive impairment;

assume responsibility for themselves, to learn how to respect however, other symptoms are necessary to establish this

and communicate with others, and to interact in a positive diagnosis.

manner.
40. Answer: D. Short words and simple sentences

Options A, B, and D: The remaining answer choices

may be outcomes of psychiatric treatment, but the use of a Short words and simple sentence minimize client confusion

therapeutic community approach is concerned with the and enhance communication.

promotion of self-reliance and cooperative adaptation to being

Options A and C: Complete explanations with multiple
with others.
details and stimulating words and phrases would increase

37. Answer: A, D, C, B, then E. confusion in a client with short attention span and difficulty with

comprehension.

The nurse should remain with the client to provide support and Option B: Although pictures and gestures may be

promote safety. Reducing external stimuli, including dimming helpful, they would not substitute for verbal communication.

lights and avoiding crowded areas, will help decrease anxiety.

Encouraging the client to use slow, deep breathing will help 41. Answer: D. Fills in memory gaps with fantasy.

promote the bodys relaxation response, thereby interrupting

Confabulation is a communication device used by patients with
stimulation from the autonomic nervous system. Encouraging
dementia to compensate for memory gaps. The remaining
physical activity will help him to release energy resulting from
answer choices are incorrect.
the heightened anxiety state; this should be done only after the

client has brought his breathing under control. Teaching coping

42. Answer: C. Remain calm and talk quietly to the client.
measures will help the client learn to handle anxiety; however,

this can only be accomplished when the clients panic has Maintaining a calm approach when intervening with an agitated
dissipated and he is better able to focus. client is extremely important.

38. Answer: C. 0.5 Option A: Telling the client firmly that it is time to get

dressed may increase his agitation, especially if the nurse

Set up the problem as follows: 2.5mg/10mg = Xml/2ml X=0.5ml
touches him.
Option B: Restraints are a last resort to ensure client
39. Answer: C. Orientation
safety and are inappropriate in this situation.

The initial, most basic assessment of a client with cognitive Option D: Sedation should be avoided, if possible,

impairment involves determining his level of orientation because it will interfere with CNS functioning and may

(awareness of time, place, and person). contribute to the clients confusion.

Options A and D: The nurse may also assess for 43. Answer: C. Sundowning

confabulation and perseveration in a client with cognitive

Sundowning is a common phenomenon that occurs after
impairment, but the questions in this situation would not elicit
daylight hours in a client with a cognitive impairment disorder.
the symptom response.
The other options are incorrect responses, although all may be

seen in this client.

 44. Answer: D. The client will follow an establishing helpful and not helpful, the approach suggested in this option
schedule for activities of daily living. implies the parents behavior is at fault.

Following established activity schedules is a realistic 47. Answer: A. Boundaries

expectation for clients with dementia.

Family boundaries are parameters that define who is inside
Options A, B, and C: All of the remaining outcome and outside the system. The best method of obtaining this

statements require a higher level of cognitive ability than can information is asking the family directly who they consider to be

be realistically expected of clients with this disorder. members.

45. Answer: C. The familys perception of the current Options B, C, and D: The question asked by the nurse
problem would not elicit information about the familys ethnicity or

culture, nor does it address the nature of the family

The familys perception of the problem is essential because relationship.
change in any one part of a family system affects all other parts

and the system as a whole. Each member of the family has 48. Answer: B. Development of autonomy within the family

been affected by the current problems related to the school

system and the nurse would be interested in the data. Options Differentiation is the process of becoming an individual

A and D: The childs performance in school and the teachers developing autonomy while staying in contact with the family

attempts to solve the problem are relevant and may be system.

assessed; however, priority would be given to the familys

Option A: Cooperative action among family members
perception of the problem. Option B: The family education and
does not refer to differentiation, although individuals who have
work history may be relevant, but are not a priority.
a high level of differentiation would be able to accomplish

46. Answer: B. Explain the biological nature of cooperative action.

schizophrenia. Option C: Incongruent messages in which the

recipient is a victim describe double-bind communication.

The parents are feeling responsible and this inappropriate self- Option D: Maintenance of system continuity or

blame can be limited by supplying them with the facts about the equilibrium is homeostasis.

biologic basis of schizophrenia.

49. Answer: D. The nurse should remain objective and

Option A: Acknowledging the patients responsibility is encourage mutual negotiation of issues.

neither accurate nor helpful to the parents and would only

reinforce their feelings of guilt. The nurse who wishes to be helpful to the entire family must

Option C: Support groups are useful; however, the remain neutral. Taking sides in a conflict situation in a family

nurse needs to handle the parents self-blame directly instead will not encourage negotiation, which is important for problem

of making a referral for this problem. resolution.

Option D: Teaching the parents various ways to

Option A: If the nurse aligned with the adolescent,
change would reinforce the parental assumption of blame;
then the nurse would be blaming the parents for the childs
although parents can learn about schizophrenia and what is
current problem; this would not help the familys situation.

Learning to negotiate conflict is a function of a healthy family.

 Options B and C: Encouraging the parents to adopt think and act alike. The child who always acts to please her

more realistic rules or the adolescent to comply with parental parents is an example of how enmeshment affects

rules does not give the family an opportunity to try to resolve development in many cases, a child who develops anorexia

problems on their own. nervosa exerts control only in the area of eating behavior.

50. Answer: C. Enmeshment Options A, B, and D: The remaining options are not

appropriate to the situation described.

Enmeshment is a fusion or over involvement among family

members whereby the expectation exists that all members