1.A client is fearful of driving and enters a behavioral therapy
program to help him overcome his anxiety. Using systematic
desensitization, he is able
... [Show More] to drive down a familiar street without
experiencing a panic attack. The nurse should recognize that to
continue positive results, the client should participate in which of
the following?
a. Biofeedback
b. Therapist modeling
c. Frequent pacing
d. Positive reinforcement correct answer: a. Biofeedback
2. A nurse is counseling a client following the death of the client's
partner 8 months ago. Which of the following client statements
indicates maladaptive grieving?
a. "I am so sorry for the times I was angry with my partner."
b. "I like looking at his personal items in the closet."
c. "I find myself thinking about my partner often."
d. "I still don't feel up to returning to work." correct answer: d. "I still don't feel up to returning to work."
Rationale: 8 months too long Maladaptive Grief: . Distorted or exaggerated grief response - unable to
perform activities of daily living.
RISK FACTORS FOR MALADAPTIVE GRIEVING
●● Being dependent upon the deceased
●● Unexpected death at a young age, through violence, or by a socially unacceptable manner
●● Inadequate coping skills or lack of social support
●● Pre-existing mental health issues, such as depression or substance use disorder
3./21 A nurse in an inpatient mental health facility is assessing a
client who has schizophrenia and is taking haloperidol (antipsychotic,
1st gen).
Which of the following clinical findings is the nurse's priority?
a. Headache
b. Insomnia (sedation)
c. Urinary hesitancy (Complication → ANTIcholinergic effects)
d. High fever (Complication → agranulocytosis) correct answer: d. High fever (Complication → agranulocytosis)
Other complications: Acute dystonia, Pseudoparkinsonism, Akathisia, Tardive dyskinesia,
Neuroendocrine effects (Gynecomastia, Weight gain, Menstrual irregularities), NMS,
Orthostatic Hypotension, Sedation, Sexual dysfunction, Skin effects, Liver impairment
4. A nurse is planning care for a client who has obsessive
compulsive disorder. Which of the following recommendations
should the nurse include in the client's plan of care?
a. Reality Orientation therapy (re-orient to reality)
b. Operant Conditioning (receives positive rewards for positive behavior)
c. Thought Stopping (say "stop" when compulsive behaviors arise & substitute
w/ positive thought)
d. Validation Therapy (acknowledging pt's feelings) correct answer: c. Thought Stopping (say "stop" when compulsive behaviors arise & substitute
w/ positive thought)
5. A nurse is caring for a client who is in the manic phase of
bipolar disorder. Which of the following actions should the
nurse take?
a. Provide in depth explanation of nursing expectations
(inability to focus - give concise explanations)
b. Encourage the client to participate in group activities
(decrease stimulation)
c. Avoid power struggles by remaining neutral (do not react
personally to pt's comments)
d. Allow the client to set limits for his behavior (nurse sets limits) correct answer: c. Avoid power struggles by remaining neutral (do not react
personally to pt's comments)
6. A nurse is providing behavioral therapy for a client who has
OCD. The client repeatedly checks that the doors are locked at
night. Which of the following instructions should the nurse give
the client when using thought stopping technique?
a. "Keep a journal of how often you check the locks each
night."
b. "Ask a family member to check the locks for you at night."
c. "Focus on abdominal breathing whenever you go to
check the locks."
d. "Snap a rubber band on your wrist when you think about
checking the locks." correct answer: d. "Snap a rubber band on your wrist when you think about
checking the locks."
Thought stopping: teach pt to say "stop" when negative
thoughts/compulsive behaviors arise & substitute positive thought - goal forpt use command silently over time
7. A nurse is caring for a client who has a cocaine use disorder.
Which of the following manifestations should the nurse expect
the client to have during withdrawal?
a. Hand tremors (Intoxication)
b. Fatigue
c. Seizures (Intoxication)
d. Rapid speech
Rationale: Pg: 97 WITHDRAWAL MANIFESTATIONS● Depression, fatigue, craving, excess sleeping or
insomnia, dramatic unpleasant dreams, psychomotor retardation, agitation ● Not life-threatening, but
possible occurrence of suicidal ideation
Cocaine = STIMULANT → OPPOSITE of HEROIN
● Withdrawal = opposite effects correct answer: b. Fatigue
8. A nurse is reviewing the medical record of a client who is taking
clozapine. For which of the following findings should the nurse
withhold the medication and notify the provider?
a. WBC count
b. Heart rate
c. Report of photosensitivity
d. Blood glucose level correct answer: a. WBC count
9./59. A nurse is creating a plan of care for a client who has
major depressive disorder. Which of the following interventions
should the nurse include in the plan?
a. Keep the ring light on in the client's room at night
b. Encourage physical activity for the client during the day
c. Identity and schedule alternative group activities for the
client
d. Discourage the client from expressing feeling of anger correct answer: b. Encourage physical activity for the client during the day
10. A nurse is assessing a client who is experiencing acute
alcohol withdrawal. Which of the following findings should the
nurse expect?
a. Diminished reflexes
b. Hypotension - increased BP
c. Insomnia
d. Bradycardia correct answer: c. Insomnia
11. A nurse is caring for a client who has schizophrenia and
displays severe symptoms of the disorder. Which of the following
actions should the nurse take?
a. Use medication to decrease frequency of auditory
and visual hallucinations
b. Assist the client to identify somatic and thought broadcast
delusion
(Identify symptom triggers, such as loud noises (can trigger auditory hallucinations in certain clients)
and situations that seem to trigger conversations about the client's delusions.
c. Manage the client's loud, rambling, and incoherent
communication patterns
d. Direct the client to perform her own daily hygiene
and grooming tasks correct answer: d. Direct the client to perform her own daily hygiene
and grooming tasks
Somatic delusions - believes that his body is changing in an unusual way, such as growing a third arm.
Thought broadcasting - believes that her thoughts are heard by others.
Schizophrenia: The client has psychotic thinking or behavior present for at least 6 months. Areas of
functioning, including school or work, self-care, and interpersonal relationships, are significantly
impaired.
12. A nurse is caring for a client who was involuntarily committed
and is scheduled to receive electroconvulsive therapy. The client
refuses the treatment and will discuss why with the healthcare
team. Which of the following actions should the nurse take?
a. Document the client's refusal of the treatment in
the medication record
b. Tell the client he cannot refuse the treatment
because he was involuntarily committed [Show Less]